Surgery is the safest option in patients with carotid artery stenosis who are treated within 7 days of symptom onset, pooled analysis confirms.
Patients treated for carotid artery disease within 7 days of symptom onset are at lower risk of stroke or death in the following month if they undergo endarterectomy rather than stenting, according to a pooled analysis of four major trials.
“There have been a lot of studies on the influence of timing of treatment [of symptomatic carotid artery stenosis], but only for carotid endarterectomy,” lead author Barbara Rantner, MD, (Medical University of Innsbruck, Innsbruck, Austria), told Neurovascular Exchange in an email. “There was little evidence, so far, on the influence of timing on the outcome of carotid artery stenting.”
For their study published online April 28, 2017, in Stroke, Rantner and colleagues conducted a pooled analysis of individual data on 4,138 patients from four randomized trials: EVA-3S, SPACE, ICSS, and CREST.
Overall, only 14% of patients who underwent stenting and 11% of patients who underwent endarterectomy were treated within 7 days of symptom onset. Those given stents within that time frame had a higher risk of stroke or death than those treated with endarterectomy after adjusting for age at treatment, sex, and type of qualifying event. Stenting was not significantly more hazardous than endarterectomy when performed after 7 days.
Risk of Stroke or Death by Treatment Timing
|
|
Stenting |
Endarterectomy |
Adjusted Risk Ratio (95% CI) |
|
0-7 Days After Symptom Onset |
8.3% |
1.3% |
6.7 (2.1–21.9) |
|
>7 Days After Symptom Onset |
7.1% |
3.6% |
2.0 (1.5-2.7) |
According to Rantner, the findings demonstrate that endarterectomy “in the early days after symptom onset is safe and remains treatment of choice for stroke prevention.” They also mirror those of an earlier analysis conducted by the same team in 2013. “We hoped to confirm the results from 2013 and wanted to reach statistical significance for the timing differences, and this was achieved,” she said, “with an additional 1,000 patients from CREST.”
Overall, Rantner concluded, “We confirmed the finding that early surgery is safe and effective in stroke prevention.”
Questions remain, though. “Recent literature indicates that the stroke recurrence rate might be lower than so far documented with improved best medical treatment in the acute period after the onset of neurological symptoms,” Rantner pointed out. “This needs to be confirmed, however, in a larger series of symptomatic patients.”
She also noted that the major limitation of her study is that data on procedure time were not collected prospectively.
Source:
Rantner B, Kollerits B, Roubin GS, et al. Early endarterectomy carries a lower procedural risk than early stenting in patients with symptomatic stenosis of the internal carotid artery: results from 4 randomized controlled trials. Stroke. 2017;Epub ahead of print.
Disclosures:
Rantner reports no relevant conflicts of interest.
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