Carotid Artery Stenting Versus Endarterectomy for Stroke Prevention

Sardar, Partha; Chatterjee, Saurav; Aronow, Herbert D.; Kundu, Amartya; Ramchand, Preethi; Mukherjee, Debabrata; Nairooz, Ramez; Gray, William A.; White, Christopher J.; Jaff, Michael R.; Rosenfield, Kenneth; Giri, Jay

doi:10.1016/j.jacc.2017.02.053

Cited by 135 publications

(105 citation statements)

References 26 publications

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“…Brahmanandam et al 45 and Liu et al 46 also found CEA to be superior to CAS for periprocedural stroke or death. However, CEA has also been associated with an increased risk of periprocedural MI, 17,46 a finding consistent with our observation that CEA confers no benefit for MI. We previously conducted a meta-analysis in all carotid stenosis patients 18 and found that CAS was associated with decreased risks of periprocedural MI, hematoma, and cranial nerve palsy but with increased risks of periprocedural and long-term stroke.…”

Section: Discussionsupporting

confidence: 87%

“…The Cochrane review 11 found a trend toward increased risk of periprocedural death or stroke after CAS or angioplasty (MantelHaenszel odds ratio for 3 trials: 1.71; 95% CI, 0.78-3.76), a result similar to but less precise than that reported in the present study. The inputs into a recent meta-analysis by Sardar et al 17 that considered asymptomatic patients as a subgroup analysis were similar or identical to ours, differing only when we included more studies (for any periprocedural stroke) or when Sardar et al 17 included outcomes from SAPPHIRE (for periprocedural MI) or ACT I (for long-term stroke) that we could not independently verify. Our reported results were similar to those of Sardar et al, 17 even where inputs were discrepant.…”

Section: Discussionmentioning

confidence: 83%

“…The inputs into a recent meta-analysis by Sardar et al 17 that considered asymptomatic patients as a subgroup analysis were similar or identical to ours, differing only when we included more studies (for any periprocedural stroke) or when Sardar et al 17 included outcomes from SAPPHIRE (for periprocedural MI) or ACT I (for long-term stroke) that we could not independently verify. Our reported results were similar to those of Sardar et al, 17 even where inputs were discrepant. The results of previous systematic reviews and meta-analyses of all patients (asymptomatic+symptomatic) are also consistent with our results.…”

Section: Discussionmentioning

confidence: 83%

“…12 Notably, both of these systematic reviews considered only a small subset of relevant outcomes, and neither of them included influential randomized controlled trials (RCTs) that were recently published 13 or produced follow-up reports 14,15 that may improve the precision of pooled effect estimates. More recent and comprehensive meta-analyses have focused on all patients [16][17][18] and have not adequately assessed patients with asymptomatic carotid stenosis. Given the uncertainty about the best revascularization method for asymptomatic carotid stenosis patients and the potential for an up-to-date systematic review to reduce this clinically important knowledge gap, we conducted a systematic review and meta-analysis of the comparative efficacy and safety of CAS versus CEA in asymptomatic carotid stenosis patients with respect to stroke, MI, cranial nerve palsy, hematoma, death, and combinations of these events in the periprocedural period and thereafter.…”

mentioning

confidence: 99%

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Carotid Stenting Versus Endarterectomy for Asymptomatic Carotid Artery Stenosis

Moresoli

Habib

Reynier

et al. 2017

Stroke

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Background and Purpose— There is no consensus on the comparative efficacy and safety of carotid artery stenting (CAS) versus carotid endarterectomy (CEA) in patients with asymptomatic carotid artery stenosis. To evaluate CAS versus CEA in asymptomatic patients, we conducted a systematic review and meta-analysis of randomized controlled trials. Methods— We systematically searched EMBASE, PubMed, MEDLINE, and the Cochrane Library for randomized controlled trials comparing CAS to CEA in asymptomatic patients using a pre-specified protocol. Two independent reviewers identified randomized controlled trials meeting our inclusion/exclusion criteria, extracted relevant data, and assessed quality using the Cochrane risk of bias tool. Random effects models with inverse-variance weighting were used to estimate pooled risk ratios (RRs) comparing the incidences of periprocedural and long-term outcomes between CAS and CEA. Results— We identified 11 reports of 5 randomized controlled trials for inclusion (n=3019) asymptomatic patients. The pooled incidences of any periprocedural stroke (RR, 1.84; 95% confidence interval [CI], 0.99–3.40), periprocedural nondisabling stroke (RR, 1.95; 95% CI, 0.98–3.89), and any periprocedural stroke or death (RR, 1.72; 95% CI, 0.95–3.11) trended toward an increased risk after CAS. We could not rule out clinically significant differences between treatments for long-term stroke (RR, 1.24; 95% CI, 0.76–2.03) and the composite outcome of periprocedural stroke, death or myocardial infarction, or long-term ipsilateral stroke (RR, 0.92; 95% CI, 0.70–1.21). Conclusions— Although uncertainty surrounds the long-term outcomes of CAS versus CEA, the potential for increased risks of periprocedural stroke and periprocedural stroke or death with CAS suggests that CEA is the preferred option for the management of asymptomatic carotid stenosis.

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Section: Discussionsupporting

confidence: 87%

Section: Discussionmentioning

confidence: 83%

Section: Discussionmentioning

confidence: 83%

mentioning

confidence: 99%

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Carotid Stenting Versus Endarterectomy for Asymptomatic Carotid Artery Stenosis

Moresoli

Habib

Reynier

et al. 2017

Stroke

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“…2) However, periprocedural minor stroke may occur in most patients. 3) A study reported that the results of tailored CAS in which devices were adequately selected for high-risk patients for CEA were similar to those of CEA, with recent advances in protection procedures. 4) In particular, a proximal protection device, MOMA, has facilitated safe treatment for patients in whom CAS was previously considered to be difficult.…”

Section: Discussionmentioning

confidence: 98%

Importance of Predilatation for CAS: Two Patients for Whom Balloons Were Mis-selected

Matsushita

Sogabe

Suzue

et al. 2018

JNET

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Objective:We report two patients for whom balloons for carotid artery stenting (CAS) were mis-selected, and review balloon selection for CAS and the purpose of predilatation.Case Presentations: Case 1: A 73-year-old man developed amaurosis fugax on his right eye. An unstable, plaqueabundant stenotic lesion of the right internal carotid artery with calcification was detected. Under flow reversal, a Carotid WALLSTENT 8 mm × 29 mm was inserted, and postdilatation was performed using a Jackal 4.5 mm × 30 mm until a nominal pressure was achieved. In-stent plaque protrusion was noted. A Carotid WALLSTENT 8 mm × 21 mm was overlapped, and the procedure was completed. Subacute thrombosis (SAT) with North American Symptomatic Carotid Endarterectomy Trial (NASCET) 40% restenosis was observed 5 days after CAS. Anticoagulant therapy gradually reduced SAT.Case 2: An 83-year-old woman presented an asymptomatic acute phase ischemic lesion in left cerebral hemisphere by scheduled MRI as a follow-up study of medical checkup. An irregular, plaque-abundant, markedly stenotic lesion of the left internal carotid artery with calcification was detected. Under flow reversal, predilatation was performed using a Sterling 3 mm × 40 mm (Boston Scientific, Marlborough, MA, USA) until a nominal pressure was achieved, and a PRECISE 9 mm × 40 mm (Cardinal Health, Inc., Dublin, OH, USA) was inserted. It was impossible to pass an Aviator 4 mm x 30 mm (Cardinal Health, Inc.) for postdilatation through the site of stenosis, and a Gateway 2.5 mm × 12 mm (Stryker, Kalamazoo, MI, USA) and Jackal 4.5 mm × 30 mm (Kaneka Medix Corp., Osaka, Japan) were used. Dilatation was achieved. Conclusion:To improve the results of CAS, it is important to establish the purpose of balloon dilatation and select a balloon in accordance with its purpose, as indicated for the selection of embolic protection devices (EPDs) and stents.

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Association of Transcarotid Artery Revascularization vs Transfemoral Carotid Artery Stenting With Stroke or Death Among Patients With Carotid Artery Stenosis

Schermerhorn

Liang

Eldrup-Jørgensen

et al. 2019

JAMA

192

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IMPORTANCE Several trials have observed higher rates of perioperative stroke following transfemoral carotid artery stenting compared with carotid endarterectomy. Transcarotid artery revascularization with flow reversal was recently introduced for carotid stenting. This technique was developed to decrease stroke risk seen with the transfemoral approach; however, its outcomes, compared with transfemoral carotid artery stenting, are not well characterized. OBJECTIVE To compare outcomes associated with transcarotid artery revascularization and transfemoral carotid artery stenting. DESIGN, SETTING, AND PARTICIPANTS Exploratory propensity score-matched analysis of prospectively collected data from the Vascular Quality Initiative Transcarotid Artery Surveillance Project and Carotid Stent Registry of asymptomatic and symptomatic patients in the United States and Canada undergoing transcarotid artery revascularization and transfemoral carotid artery stenting for carotid artery stenosis, from September 2016 to April 2019. The final date for follow-up was May 29, 2019. EXPOSURES Transcarotid artery revascularization vs transfemoral carotid artery stenting. MAIN OUTCOMES AND MEASURESOutcomes included a composite end point of in-hospital stroke or death, stroke, death, myocardial infarction, as well as ipsilateral stroke or death at 1 year. In-hospital stroke was defined as ipsilateral or contralateral, cortical or vertebrobasilar, and ischemic or hemorrhagic stroke. Death was all-cause mortality.RESULTS During the study period, 5251 patients underwent transcarotid artery revascularization and 6640 patients underwent transfemoral carotid artery stenting. After matching, 3286 pairs of patients who underwent transcarotid artery revascularization or transfemoral carotid artery stenting were identified (transcarotid approach: mean [SD] age, 71.7 [9.8] years; 35.7% women; transfemoral approach: mean [SD] age, 71.6 [9.3] years; 35.1% women). Transcarotid artery revascularization was associated with a lower risk of in-hospital stroke or death (1.6% vs 3.

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Carotid Artery Stenting Versus Endarterectomy for Stroke Prevention

Cited by 135 publications

References 26 publications

Carotid Stenting Versus Endarterectomy for Asymptomatic Carotid Artery Stenosis

Carotid Stenting Versus Endarterectomy for Asymptomatic Carotid Artery Stenosis

Importance of Predilatation for CAS: Two Patients for Whom Balloons Were Mis-selected

Association of Transcarotid Artery Revascularization vs Transfemoral Carotid Artery Stenting With Stroke or Death Among Patients With Carotid Artery Stenosis

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