Long-Term Outcomes of Carotid Endarterectomy and Carotid Artery Stenting When Performed by a Single Vascular Surgeon

Abstract

Objectives: Carotid artery endarterectomy (CEA) and carotid artery stenting (CAS) are 2 effective treatment options for carotid revascularization and stroke prevention. The long-term outcomes of Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) reported similar stroke and death rate between the 2 procedures. This study presents the short-and longterm outcomes of CEA and CAS of all risk patients performed by a single vascular surgeon in a real-world setting. Methods: We retrospectively reviewed all patients who underwent CEA and CAS from September 2005 to June 2017 at our institute. Student t test, w 2 , and Fisher exact tests were used to compare patient's characteristics. Multivariate logistic, cox regression models and survival analysis were used to compare postoperative and long-term outcomes between the 2 groups. Results: Over 2000 patients were evaluated for carotid artery stenosis during the study period, and 313 revascularization procedures were performed (CEA: 47%, CAS: 53%). Patients' age (Mean [95% confidence interval, CI] 68.8 [67.2-70.4] vs 69.7 [68.2-71.3], P ¼ .40) was similar between CEA and CAS. Patients who underwent CAS had significantly higher comorbidities (chronic obstructive pulmonary disease [COPD], chronic heart failure [CHF], hyperlipidemia, and prior ipsilateral intervention, all P < .05). No difference was found in 30-day complications after CEA versus CAS including stroke (2.0% vs 1.2%), myocardial infarction (MI; 0.7% vs 1.2%), death (0% vs 1.2%) as well as combined major adverse events (stroke/death/MI; 2.7% vs 3.0%; all P > .05). Overall 7-year survival, stroke-free survival and restenosis-free survival were similar between the 2 groups (P > .5). Significant predictors of mortality were diabetes (hazard ratio, HR [95% CI]: 2.41 [1.15-5.08]), chronic kidney disease (HR [95% CI]: 4.89 [1.97-12.13]), and COPD (HR [95% CI]: 3.31 [1.43-7.71]; all P values <.05). Statin use was protective with 71% reduction in risk of mortality (HR [95% CI]: 0.29 [0.12-0.67], P ¼ .004). Conclusion: Our experience showed comparable short-and long-term outcomes of CAS and CEA performed for carotid artery stenosis by vascular surgeon. There was no difference between single institutional long-term outcomes and CREST outcomes following CEA and CAS.

Early Outcomes of Carotid Revascularization in Retrospective Case Series

“…The study cohorts ranged from 65 to 6940 patients. All articles presented the results of observational, retrospective, comparative studies [11][12][13][14][15][16][17][18][19][20][21][22][23][24][25]. The studies' characteristics are shown in Table 1.…”

“…The distribution of asymptomatic carotid disease was higher in both groups (79.8% in CAS and 64.8% in CEA). In CAS, embolic protection was used in 3911 patients (90.1%), while in four studies the use of a filter or other protection device was not recorded [11,19,22,25].…”

Restenosis rates in patients with ipsilateral carotid endarterectomy and contralateral carotid artery stenting

“…According to the results of large RCTs, it can be clearly stated that, among the long-term outcomes, there is no significant difference between CEA and CAS in the incidence of ipsilateral stroke [2,6,7,12,13]. However, concerning restenosis, the literature data are rather contradictory; while RCTs have shown that CAS has a higher rate of restenosis [2,14,15], observational studies have noted that CEA has a higher rate of restenosis [16][17][18].…”

Comparison of the Outcome and Efficacy of Single-Layer versus Dual-Layer Mesh Stent among Carotid Stenosis Patients Attending a Tertiary Care Setting—A Prospective Observational Study

“…In contrast, conventional CAS does not remove plaque but seeks to stabilize the potentially embolic lesion by covering it with a layer of the metallic stent and subsequent stable fibrous tissue layer (healing). 7 One of the major causes of ischemic complications after stent deployment in patients with unstable plaques is PP through stent struts. Open-cell stent devices have a higher risk of periprocedural stroke compared with closed-cell devices.…”

“…In contrast, conventional CAS does not remove plaque but seeks to stabilize the potentially embolic lesion by covering it with a layer of the metallic stent and subsequent stable fibrous tissue layer (healing). 7…”