Comparative Effectiveness of Commonly Used Devices for Carotid Artery Stenting: An NCDR (National Cardiovascular Data Registry) Analysis
What is the comparative effectiveness of the most commonly used stent/emboli protection devices (EPDs) in patients undergoing carotid artery stenting (CAS)?
The authors analyzed 12,135 consecutive carotid stent procedures in the NCDR (National Cardiovascular Data Registry) CARE (Carotid Artery Revascularization and Endarterectomy) registry performed between January 1, 2007 and March 31, 2012. Baseline characteristics and crude and multivariable-adjusted rates of in-hospital combined death/stroke were compared among patients treated with Acculink/Accunet (Abbott Laboratories, Abbott Park, IL), Xact/Emboshield (Abbott), and Precise/Angioguard (Cordis Corporation, Bridgewater, NJ) stent/EPD combinations.
In the majority (78%) of cases, stents were used in conjunction with their specific, corresponding US Food and Drug Administration–approved EPD. The Xact/Emboshield (n = 3,507, 28.9%) was most commonly used, followed by Precise/Angioguard (n = 2,696, 22.2%) and the Acculink/Accunet (n = 2,617, 21.6%) stent/EPD combination. The Protégé/SpiderFx (ev3 Endovascular Inc., Plymouth, MN) (n = 453, 3.7%) and Wallstent/Filterwire (Boston Scientific, Natick, MA) (n = 213, 1.8%) were infrequently used. There was a borderline difference in the primary endpoint of death/stroke in patients treated with the Precise/Angioguard system compared with the Acculink/Accunet (2.5% vs. 1.8%; p = 0.058) and similar results when compared with the Xact/Emboshield (2.5% vs. 1.9%; p = 0.14). In adjusted analyses, there was no significant difference between Precise/Angioguard and Accunet/Acculink (odds ratio [OR], 1.48; 95% confidence interval [CI], 0.89-2.47; p = 0.065), Precise/Angioguard and Xact/Emboshield (OR, 1.16; 95% CI, 0.77-1.76; p = 0.38), and Xact/Emboshield and Accunet/Acculink (OR, 1.28; 95% CI, 0.82-1.97; p = 0.18). The Precise/Angioguard system was associated with a significantly higher rate of stroke compared with the Xact/Emboshield system (2.3% vs. 1.7%; p = 0.02) and with a trend toward a higher stroke rate than the Accunet/Acculink system (2.3% vs. 1.6%; p = 0.06). There was no difference in the stroke rate between the Accunet/Acculink and Xact/Emboshield systems (1.6% vs. 1.7%; p = 0.84).
The authors concluded that the commonly used stent/EPD combinations are associated with similar clinical outcomes.
This paper nicely demonstrates the utility of large clinical registries. The study provides a real-world comparative effectiveness of the most commonly used devices for CAS, a subject for which there are no randomized data. All the commonly used devices are associated with similar excellent outcome, and operator preference and experience should continue to guide choice of the EPD/stent for carotid stenting.
Clinical Topics: Invasive Cardiovascular Angiography and Intervention
Keywords: Endarterectomy, Stroke, Embolic Protection Devices, United States Food and Drug Administration, Carotid Arteries, Stents
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