Systematic Comparison of the Early Outcome of Angioplasty and Endarterectomy for Symptomatic Carotid Artery Disease

Abstract

Background and Purpose —Endoluminal treatment is being increasingly used for carotid artery disease. The aim of this study was to compare the stroke and death risk within 30 days of endovascular treatment or endarterectomy for symptomatic carotid artery disease. Methods —A systematic comparison of the 30-day outcome of angioplasty with or without stenting and endarterectomy for symptomatic carotid artery disease reported in single-center studies, published since 1990, was performed. Results —Thirty-three studies (13 angioplasty and 20 carotid endarterectomy) were included in this analysis. Carotid stents were deployed in 44% of angioplasty patients. Mortality within 30 days of angioplasty was 0.8% compared with 1.2% after endarterectomy (OR 0.68, 95% CI 0.43 to 1.05; P =0.6). The stroke rate was 7.1% for angioplasty and 3.3% for endarterectomy (OR 2.22, CI 1.62 to 3.04; P <0.001), while the risk of fatal or disabling stroke was 3.2% and 1.6%, respectively (OR 2.09, CI 1.3 to 3.33; P <0.01). The risk of stroke or death was 7.8% for angioplasty and 4% for endarterectomy (OR 2.02, CI 1.49 to 2.75; P <0.001), while disabling stroke or death was 3.9% after angioplasty and 2.2% after endarterectomy (OR 1.86, CI 1.22 to 2.84; P <0.01). Conclusions —In the treatment of symptomatic carotid artery disease, the risk of stroke is significantly greater with angioplasty than carotid endarterectomy. At present, carotid angioplasty is not recommended for the majority of patients with symptomatic carotid artery disease.

Early Outcome of Carotid Angioplasty and Stenting With and Without Cerebral Protection Devices

“…The combined stroke and death rate within 30 days of 6.4% in symptomatic patients is in the range of 7.8% found in a recent survey of the literature, in which most symptomatic patients had been treated with angioplasty alone. 5 Although a comparison between these 2 reviews should be made with caution because of the wide heterogeneity in patients and study designs, the similar complication rates indicate that the additional stent deployment does not increase clinically relevant thromboembolic complications. While this might appear self-evident, the insertion of a stent is associated with an increased occurrence of microembolic signal as detected by transcranial Doppler, 54 which could lead to more thromboembolic complications.…”

“…4 In contrast, a recent systematic comparison of the 30-day outcome of CAS and CEA for symptomatic CAD in single-center studies performed during 1990 -1999 revealed a significantly higher risk of stroke or death for CAS than for CEA. 5 Both this survey and CAVA-TAS elucidate the great challenges associated with the performance of trials comparing CEA with CAS. The field of endovascular therapy is subject to rapid technological advances.…”

Analysis of Emboli during Carotid Stenting with Distal Protection Device

“…Recent studies demonstrated that CAS has comparable outcomes and complication rates with CEA [20, 21] despite the fact that CAS produces more emboli compared with CEA on TCD [4, 22] or silent strokes on MRI [23, 24]. CAS with the distal protection device had less clinical complications [7, 25] and emboli formation [26] than CAS without protection.…”

Durability of Carotid Endarterectomy

“…35 Since the year 2000, 7 studies have been published with larger sample sizes (mean, 222 patients; range, 99 to 528) and 14.9-month follow-up (range, 11.2 to 20 months). 36 -41 The reported 30-day stroke and death rates range from 1% to 4%, with early restenosis rates of 0.5% to 14% (Table 3).…”