The Source for Neurovascular News and Education

June 17, 2019


But older patients who receive stents are at increased risk for stroke or death for up to 30 days postprocedure.


The increased procedural risk of stroke or death associated with stenting versus endarterectomy for symptomatic carotid artery occlusion is mainly confined to the first day after treatment, according to a meta-analysis analysis published online October 1, 2018, ahead of print in Stroke.


“In patients with recently symptomatic carotid stenosis, carotid artery stenting is associated with a higher risk of stroke or death in the procedural period (defined as within 30 days of treatment) than carotid endarterectomy,” write the authors, led by Mandy D. Müller, MD (University Hospital Basel, University of Basel, Switzerland). “This extra risk associated with stenting is mostly attributed to an increase in minor or nondisabling strokes occurring in patients > 70 years. Beyond the procedural period, stenting seems to be as effective as endarterectomy in preventing recurrent stroke.”


What remains unclear, they point out, is whether this increased risk of events occurs only in the first day following the procedure or whether it remains for 30 days thereafter.


To find out, the investigators analyzed the risk of stroke or death occurring on the day of procedure (ie, immediate procedural events) and within 1 to 30 days thereafter (ie, delayed procedural events) among 4,597 patients with symptomatic carotid stenosis who underwent carotid artery stenting (n = 2,326) or endarterectomy (n = 2,271) in four randomized trials: EVA-3S, SPACE, CREST, and ICSS.


Compared with patients who underwent endarterectomy, patients treated with stenting were at greater risk for immediate but not delayed procedural events (P for interaction = 0.006)


Risk of Procedural Events – Stenting vs Endarterectomy



(n = 2,326)


(n = 2,217)

OR (95% CI)


110 (4.7%)

42 (1.9%)

2.6 (1.9-3.8)


59 (2.5%)

46 (2.0%)

1.3 (0.9-1.9)


Age Plays a Role


Among stented patients, older age was associated with an increased risk of both immediate and delayed procedural events. In contrast, the severity of the qualifying event only increased the risk of delayed events.


Among patients treated with endarterectomy, the investigators did not identify any risk factors for immediate procedural events. A higher level of disability at baseline and known history of hypertension, however, were associated with delayed procedural events.


“This finding demonstrates the need to enhance the procedural safety of carotid artery stenting by technical improvements of the procedure and increased operator skill,” conclude the authors. They also recommend further investigating the role of age in increasing the risk of procedural events among patients undergoing stenting.




Müller MD, von Felten S, Algra A, et al. Immediate and delayed procedural stroke or death in stenting versus endarterectomy for symptomatic carotid stenosis. Stroke 2018;Epub ahead of print.



Müller reports no relevant conflicts of interest.