Long-Term Results of Stenting versus Endarterectomy for Carotid-Artery Stenosis

Abstract

BACKGROUND In the Carotid Revascularization Endarterectomy versus Stenting Trial, we found no significant difference between the stenting group and the endarterectomy group with respect to the primary composite end point of stroke, myocardial infarction, or death during the periprocedural period or any subsequent ipsilateral stroke during 4 years of follow-up. We now extend the results to 10 years. METHODS Among patients with carotid-artery stenosis who had been randomly assigned to stenting or endarterectomy, we evaluated outcomes every 6 months for up to 10 years at 117 centers. In addition to assessing the primary composite end point, we assessed the primary end point for the long-term extension study, which was ipsilateral stroke after the periprocedural period. RESULTS Among 2502 patients, there was no significant difference in the rate of the primary composite end point between the stenting group (11.8%; 95% confidence interval [CI], 9.1 to 14.8) and the endarterectomy group (9.9%; 95% CI, 7.9 to 12.2) over 10 years of follow-up (hazard ratio, 1.10; 95% CI, 0.83 to 1.44). With respect to the primary long-term end point, postprocedural ipsilateral stroke over the 10-year follow-up occurred in 6.9% (95% CI, 4.4 to 9.7) of the patients in the stenting group and in 5.6% (95% CI, 3.7 to 7.6) of those in the endarterectomy group; the rates did not differ significantly between the groups (hazard ratio, 0.99; 95% CI, 0.64 to 1.52). No significant between-group differences with respect to either end point were detected when symptomatic patients and asymptomatic patients were analyzed separately. CONCLUSIONS Over 10 years of follow-up, we did not find a significant difference between patients who underwent stenting and those who underwent endarterectomy with respect to the risk of periprocedural stroke, myocardial infarction, or death and subsequent ipsilateral stroke. The rate of postprocedural ipsilateral stroke also did not differ between groups. (Funded by the National Institutes of Health and Abbott Vascular Solutions; CREST ClinicalTrials.gov number, NCT00004732.)

Prescription of Guideline-Based Medical Therapies at Discharge After Carotid Artery Stenting and Endarterectomy

“…3 Although the long-term risk of periprocedural death or stroke is marginally higher after carotid artery stenting (CAS) than CEA, CAS has been proven equivalent to CEA for the composite end point, death, myocardial infarction, or stroke. 4 Whether evidence-based medical therapies are prescribed equally often among patients who undergo CAS and CEA has implications for overall atherothrombotic event (including stroke) risk reductions afforded by these respective revascularization modalities in the real world. Using data from the CARE registry (Carotid Artery Revascularization and Endarterectomy), we compared rates of antiplatelet agent and statin prescription at discharge among patients who underwent CAS or CEA and examined the independent influence of patient, operator, and hospital characteristics on respective prescription rates.…”

The Asymptomatic Carotid Surgery Trial-2 (ACST-2): an ongoing randomised controlled trial comparing carotid endarterectomy with carotid artery stenting to prevent stroke

“…Through the CSTC, ACST-2 investigators have secured agreement to pool individual patient data from ACST-2 and three other trials that directly compared CEA with CAS in asymptomatic patients -CREST-1 (1182 patients), SPACE-2 (Stent Protected Angioplasty in asymptomatic carotid artery stenosis versus endarterectomy) (320 patients randomised to CAS vs. CEA before three-way trial abandoned) and ACT-1 (NCT00106938: 1450 patients randomised 3 : 1 CAS vs. CEA, equivalent to two-thirds as many randomised 1 : 1) -thereby yielding the equivalent of about 2400 additional patients. [14][15][16] If ACST-2 recruits 3600 patients and pools these data with the CREST-1, SPACE-2 and ACT-1 cohorts, the resulting total of 6000 should more than suffice to identify types of patient in whom one procedure is clearly better than the other, and to assess reliably any effects on disabling and fatal stroke.…”

The year in cardiology 2016: peripheral circulation

“…U 2016. godini dugoročna klinička ravnoteža u praćenju stentiranja karotidnih arterija (CAS) u odnosu prema karotidnoj endarterektomiji (CEA) potvrđena je 10-godišnjom analizom u studiji CREST (Carotid Revascularisation Endarecteromy vs. Stenting Trial), gdje analiza pokazuje sličnu učestalost smrtnosti, moždanih udara, infarkta miokarda unutar 30 dana, ili ipsilateralnog moždanog udara do 10 godina za obje strategije (11,8 % prema 9,9 %; P = 0,51) (Tablica 1). 5 Periproceduralni moždani udar tijekom CAS-a obično je povezan s embolizacijom plaka. Randomizirana studija ACT (Asymptomatic Carotid Trial) usporedila je CAS s protekcijom od embolizacije u usporedbi s CEA-om u 1453 bolesnika s asimptomatskom karotidnom stenozom, koji nisu uzeti u obzir zbog visokoga kirurškog rizika (Tablica 1).…”

“…5 Peri-procedural stroke during CAS is often related to plaque embolization. The randomized Asymptomatic Carotid Trial (ACT) I compared CAS with embolic protection to CEA in 1453 patients with asymptomatic carotid stenosis, not considered at high surgical risk ( Table 1).…”