Even those who can undergo stenting or endarterectomy are at higher risk compared with other patients who’ve had a recent TIA or minor stroke, according to a new case-control study.
Patients deemed eligible for carotid endarterectomy or stenting for the treatment of symptomatic large artery atherosclerosis are at higher risk for vascular events both before and after treatment than are intervention-ineligible patients, according to a new case-control study. The authors conclude that such patients should therefore be included in trials that evaluate the benefits of antiplatelet agents for reducing this added risk.
“The purpose of surgical and medical management of carotid artery stenosis is to reduce the risk of ipsilateral stroke and also to decrease the rate of atherosclerotic events in other vascular beds,” write researchers led by Cristina Hobeanu, MD (Bichat Hospital, Paris, France). “In spite of this, there remains a substantial risk of major vascular events (MVE, including stroke, myocardial infarction, and vascular death) that should be addressed by new treatment strategies.”
Randomized trials designed to test antiplatelet agents for the treatment of transient ischemic attacks and minor strokes typically exclude patients scheduled for carotid endarterectomy or stenting based on the assumption that the risk of cerebrovascular events falls precipitously following these interventions, the researchers explain. But, Hobeanu et al add, they questioned the validity of this assumption.
To find out more, Hobeanu and colleagues used the TIAregistry to obtain data on 4,583 patients who experienced a recent transient ischemic attack or minor stroke. Among patients eligible for endarterectomy or stenting (cases), they calculated risk of MVE both before and after undergoing the procedure. For each of these cases, MVE risk was compared with 2 randomly selected controls, matched for age and sex, who were followed for a greater period of time than the time from the qualifying event to endarterectomy or stenting. The findings were published in the April 2017 issue of Stroke.
Median delay between the symptom onset of qualifying event and the time of endarterectomy or stenting was 11 days, with an interquartile range of 6-23 days.
Patients who underwent carotid intervention had an overall higher 1-year risk of MVE than controls. This elevated risk was higher for cases than for controls before endarterectomy or stenting as well as afterward.
Risk of Major Vascular Event
|
|
Cases (n = 187) |
Controls (n = 374) |
Adjusted OR (95% CI) |
P Value for Adjusted HR |
|
Overall |
14.8% |
5.8% |
2.40 (1.61–3.60) |
< 0.001 |
|
Preprocedural |
7.5% |
3.5% |
2.46 (1.07–5.64) |
0.03 |
|
Postprocedural |
7.0% |
2.4% |
2.64 (1.11–6.30) |
0.03 |
Patients with 50% to 99% carotid stenosis who can benefit from carotid endarterectomy or stenting have been shown to have a significant reduction in the risk of recurrence, write the authors. But these new data demonstrate that, despite this improvement, their risk remains higher than those who did not undergo a carotid intervention.
The current findings also demonstrate that the preprocedural risk of vascular events is high, even if patients undergo an intervention within the 15-day recommended time period. “This suggests that we should try to even shorten the delay of [intervention] and that more effective antithrombotic treatments should be trialed in preprocedural period in these patients,” write the authors, given that “in the CHANCE trial, dual antiplatelet therapy reduced the risk during the first days as compared with aspirin only.” They also suggest that trials studying other agents capable of reducing inflammation or its biomarkers, such as early statin therapy, proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibition, and methotrexate, should include patients eligible for carotid interventions.
Source:
Alaraj A, Esfahani DR, Hussein AE, et al. Neurosurgical emergency transfers: an analysis of deterioration and mortality. Neurosurgery. 2017;Epub ahead of print.
Disclosures:
- The study was supported through an unrestricted grant from Sanofi and Bristol Myers Squibb.
- Hobeanu reports no relevant conflicts of interest.
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