The Source for Neurovascular News and Education

November 29, 2022


Further studies are needed to assess whether treatment effect in the setting of CHD differs by age, the researchers say.


Having coronary heart disease does not alter the difference in procedural risk between carotid artery stenting (CAS) and endarterectomy (CEA), according to a new meta-analysis. Both were associated with a similar degree of increased stroke or death risk at 30 days in patients with and without CHD.


Yet the impact of CHD on procedural risk is unknown and may vary by patient age, the researchers suggest.


“The risk of CAS depends strongly on age, with increasing periprocedural risk at older ages for patients assigned to CAS and the absence of an effect of age on risk for patients assigned to CEA,” write investigators led by Eline J. Volkers, MD (University Medical Center Utrecht, the Netherlands). Clinicians may prefer CAS over CEA in patients with a CHD history due to data from randomized trials showing periprocedural MI is less common with CAS versus CEA, they say.


Volkers and colleagues combined data on 4,754 patients with symptomatic carotid stenosis from four randomized trials: EVA-3S, SPACE, ICSS, and CREST. Defining procedural risk as any stroke or death ≤ 30 days after treatment, they compared procedural risk between CEA and CAS, stratified by history of MI, angina, or coronary revascularization and by age (< 70, 70-74, and ≥ 75 years).


Overall, 1,293 patients (28%) had a history of CHD. The risk of procedural stroke or death was higher in patients with history of CHD, and the degree of increase in risk was similar for both CAS and CEA, such that the hazard ratios remained approximately the same.


Procedural Stroke or Death Events by Treatment Type



(n = 2,272)


(n = 2,214)

HR (95% CI)




1.96 (0.67-5.73)




1.93 (1.40-2.65)


There was an interaction between the effect of treatment type, history of CHD, and age on procedural risk. Among patients with CHD, the procedural risk was higher for CAS than CEA, but only among patients aged 75 and older.


Procedural Risk Among Patients With CHD: CAS vs CEA


HR (95% CI)

Age ≥ 75


Age 70-74

1.09 (0.45-2.65)

Age < 70

1.71 (0.79-3.71)


Among patients without CHD, however, procedural risk was higher in patients who underwent stenting only if they were aged 70 or older (HR 2.64; 95% CI 1.52-4.59; P for interaction= 0.09).


“Although our results suggest that CAS may be as safe as CEA up to the age of 75 years in patients with history of CHD, we did not find consistent statistical evidence for modification of treatment effect by age and history of CHD in both the per-protocol and the intention-to-treat analyses and for both outcome measures” the authors caution. “Therefore, further studies are needed to assess whether the treatment effect by age is truly different for patients with and without history of CHD.”


Volkers et al also advise that CEA should not be avoided in patients with CHD, given that the relative risk of procedural events between CAS and CEA did not differ based on CHD status. “Our results did not confirm our hypothesis that CAS is as safe as CEA in patients with history of CHD,” they acknowledge.




Volkers EJ, Algra A, Kappelle LJ, et al. Safety of carotid revascularization in patients with a history of coronary heart disease. Stroke. 2019;Epub ahead of print.



Volkers reports no relevant conflicts of interest.