In prior publications from the CREST study, it has been shown that stroke morbidity and mortality following carotid artery stenting/angioplasty carries twice the risk as from endarterectomy. At the Controversies and Updates in Vascular Surgery meeting (CACVS; 21–23 January, Paris, France), Wesley S Moore will present data showing how plaque characteristics can be used to compare periprocedural results of the two procedures.
According to previously-published CREST (Carotid revascularisation endarterectomy versus stenting trial) data, overall stroke morbidity and mortality rate for endarterectomy is 2.3% vs. 4.4% for stent/angioplasty. These data showed that patients over the age of 70 and women had higher risks of stroke following stenting or angioplasty when compared with endarterectomy. In this current analysis, we addressed the question of whether or not age and gender were surrogates for plaque characteristics that placed patients at high risk for stenting/angioplasty but not for endarterectomy.
A retrospective analysis of the prospectively acquired data from the CREST trial was carried out and plaque characteristics, as documented by contrast angiography, were obtained from the core laboratory. Demographic factors and plaque characteristic distribution of patients undergoing stenting/angioplasty and endarterectomy were compared, and we found no statistically significant differences between the two groups. However, three plaque characteristics were identified as being high risk for stenting/angioplasty but not for endarterectomy. Long lesions, dysynchronous lesions, and lesions distal to the carotid bulb were identified as high risk for stenting/angioplasty but not endarterectomy.
The median length of the lesions in CREST, as measured by contrast angiography was 12.85mm. A long lesion was defined as a lesion longer than the median. Dysynchronous or sequential lesions are those with two distinct areas of high grade stenosis within a plaque of the extracranial internal carotid artery. A distal lesion is a plaque distal to the carotid bulb but within the extracranial internal carotid artery. The stroke morbidity and mortality for patients with long lesions undergoing endarterectomy was 1.9% versus 6.1% for stenting/angioplasty (OR 3.45). Patients who underwent endarterectomy for sequential lesions had a stroke morbidity and mortality rate of 0.7% versus 5.8% for stenting/angioplasty (OR 9.21) and patients who underwent endarterectomy for distal lesions had an stroke morbidity and mortality rate of 1.6% versus 5.8% for stenting/angioplasty (odds ratio 3.55). It is noteworthy that 67% of the patients in CREST had one or more of the lesion characteristics that are now shown to be unfavorable for stenting/angioplasty.
We can now begin to identify characteristics that are unfavorable for stenting/angioplasty. Based on data from CREST, The following lesions are unfavorable: long lesions (>12.85mm); sequential lesions, and lesions distal to the carotid bulb. These characteristics can be added to other factors that have been previously identified and include: type III aortic arch, extensive atherosclerotic plaqing of the aortic arch; tortuosity of the internal carotid artery; circumferential calcification of the target lesion; and ulceration of the target lesion.
Patients with these characteristics should be excluded from transfemoral stenting/angioplasty and offered endarterectomy. In the absence of these unfavorable characteristics, the results of stenting or angioplasty should be comparable to endarterectomy.
Wesley S Moore is professor and chief, Emeritus, at the Division of Vascular and Endovascular Surgery, University of California Los Angeles Medical Center, Los Angeles, USA