Pooled patient-level data from more than 2,500 asymptomatic, non-octogenarian subjects have shown that carotid artery stenting (CAS) achieved comparable short- and long-term results to carotid endarterectomy (CEA). The findings of this analysis have been published by Jon Matsumura (University of Wisconsin, Madison, USA) and colleagues in the Journal of Vascular Surgery.
The study authors begin by detailing that asymptomatic carotid stenosis is the most frequent indication for CEA in the USA. Published trials and guidelines support CEA indications in selected patients with longer projected survival and in instances where periprocedural complications are low, they note, while transfemoral CAS with embolic protection is a newer treatment option.
With this in mind, the set out to compare outcomes in asymptomatic, non-octogenarian patients treated with CAS, versus those treated with CEA, via a widescale analysis of patient-level data.
Matsumura and colleagues report that a total of 2,544 patients with ≥70% asymptomatic carotid stenosis, who were randomised to receive CAS or CEA in addition to standard medical therapy, were included in their study. This was based on data from two large, randomised trials. One of these enrolled 1,091 patients (548 CAS; 543 CEA) and the other enrolled 1,453 asymptomatic patients who were less than 80 years of age (1,089 CAS; 364 CEA).
Independent neurologic assessment and routine cardiac enzyme screening was performed, the authors detail. The prespecified, primary composite endpoint of their study was any stroke, myocardial infarction or death during the periprocedural period, or ipsilateral stroke within four years after randomisation.
The authors report their results, stating that there was “no significant difference” in the primary endpoint between CAS and CEA (5.3% vs 5.1%; hazard ratio=1.02; 95% confidence interval, 0.7–1.5; p=0.91). In terms of the periprocedural rates for each component part of this composite endpoint, they also detail the following:
- Any stroke: 2.7% with CAS and 1.5% with CEA (p=0.07)
- Myocardial infarction: 0.6% with CAS and 1.7% with CEA (p=0.01)
- Death: 0.1% with CAS and 0.2% with CEA (p=0.62)
- Any stroke or death: 2.7% with CAS and 1.6% with CEA (p=0.07)
They go on to note that, after this period, the rates of ipsilateral stroke were “similar” between the two groups (2.3% with CAS versus 2.2% with CEA; p=0.97).
This led Matsumura and colleagues to conclude that, in a pooled analysis of two large, randomised trials of CAS and CEA in asymptomatic, non-octogenarian patients, CAS ultimately achieved comparable short- and long-term results to CEA.
Speaking to NeuroNews, Matsumura said: “The impact of this large study is that it uses the best available evidence—prospective, randomised controls, intention-to-treat analysis, federal regulatory oversight, independent neurologic exams and biochemical screening—and studies the largest population (asymptomatic, non-octogenarian patients) with severe carotid stenosis receiving interventional treatment in the USA. It has direct relevance for patient care, treatment guidelines and payor policy. It is also highly congruent with the recently published international trial, ACST-2.”
Proper selection of patients. Age and extensive calcified lesions are factors to be considered .Calcifications in the ICA can cause stent collapse and access to the CCA during a TCAR challenging.