Health-related quality of life in ischaemic stroke survivors after carotid endarterectomy (CEA) and carotid artery stenting (CAS): confounder-controlled analysis

Abstract

Introduction: Atherosclerotic carotid artery stenosis (CS)-related strokes are a significant overall stroke burden contributor. Aim: To evaluate the effect of surgical (carotid endarterectomy-CEA) vs. percutaneous (neuroprotected carotid artery stenting-CAS) carotid revascularization on health-related quality of life (HRQoL) in stroke survivors: analysis controlled for major HRQoL determinants beyond strokes. Material and methods: Our database of 856 carotid revascularization procedures (48.7% symptomatic CS) performed over 3 years showed 42 pairs (CEA-CAS) of right hemispheric stroke patients matched for age, sex, marital and educational status, hypertension, heart failure and diabetes, who underwent uneventful carotid revascularization, experienced no major adverse clinical events, and completed the Short Form Outcome Study (SF-36) questionnaire within 7 days before, 14 days after, 6 months after, and 12 months after carotid revascularization. Results: Baseline HRQoL was low and similar in both groups (30.8 ±4.6% vs. 29.1 ±3.9%, p = 0.68; data given for CEA vs. CAS). National Institute of Health Stroke Scale chronic severity was 5.4 ±2.8 vs. 5.9 ±3.1 (p = 0.44). Revascularization was associated with a major HRQoL improvement, that was significantly greater in CAS (60.4 ±9.2% vs. 71.5 ±6.2%, p < 0.001). At 6 months the CEA-CAS difference was narrower (70.7 ±9.7% vs. 74.6 ±5.9%, p = 0.026), becoming statistically insignificant at 12 months (72.6 ±6.7% vs. 75.1 ±5.1%, p = 0.062). The early CEA-CAS difference was driven by less bodily pain and better physical functioning/role-physical plus better role-emotional and higher general well-being scores in CAS (p < 0.05). Conclusions: Carotid revascularization has a major positive impact on stroke survivor patient-reported HRQoL. The improvement is initially greater in CAS, with the remaining difference small at 12 months and statistically insignificant.

Commentary: Double-Layer Carotid Stents: From the Clinical Need, through a Stent-in-Stent Strategy, to Effective Plaque Isolation… the Journey Toward Safe Carotid Revascularization Using the Endovascular Route

“…Optimally, it should prevent stroke rather than be performed in reaction to the irreversible cerebral damage that has already occurred. [12][13][14][15] One fundamental difference between the open surgical and endovascular methods of carotid revascularization is that by removing the plaque, carotid endarterectomy (CEA) eliminates the postprocedural problems of the plaque. 16 In contrast, conventional carotid artery stenting (CAS) does not remove plaque but seeks to stabilize the potentially embolic lesion by covering it with a layer of metallic stent and subsequent stable fibrous tissue layer (healing).…”

“…With the long-term equipoise of CAS and CEA in major clinical outcomes 28 (and the impropriety of "massaging" selected secondary endpoints 29 rather than using the combined endpoints for which the studies were designed and powered 3,4 ), the debate today is about periprocedural and short-term outcome differences, 3,15,29,30 invasiveness, 30 and quality of life-driven patient preferences. 10,15,25,30,31 Evidence shows that postprocedural plaque protrusion through the stent struts, which occurs in 30% to 100% of conventional carotid stents depending on the plaque type and imaging technique used, 27,32-36 is not benign. Indeed, plaque prolapse, at least one that is large enough to be depicted by angiography or intravascular ultrasound (IVUS; 2.6% to 12%), [37][38][39] occurs more frequently with vulnerable plaques.…”

“…Moreover, clinical guidelines and likewise everyday clinical decision-making should also consider the underutilized but not trivial endpoint of patientperceived quality of life. 15,30 In medicine, as in other areas of life, effective prevention is better than reactive management. Prevention relies on large-scale, reliable detection of the problem.…”

“…Optimally, it should prevent stroke rather than be performed in reaction to the irreversible cerebral damage that has already occurred. 12-15…”

“…This may occur after the period of intraprocedural cerebral protection using flow reversal techniques and/or filters. With the long-term equipoise of CAS and CEA in major clinical outcomes 28 (and the impropriety of “massaging” selected secondary endpoints 29 rather than using the combined endpoints for which the studies were designed and powered 3,4 ), the debate today is about periprocedural and short-term outcome differences, 3,15,29,30 invasiveness, 30 and quality of life–driven patient preferences. 10,15,25,30,31…”