Stenting may increase risk of stroke or death compared with endarterectomy, researchers report.
Endarterectomy appears to be a better option than stenting for the treatment of asymptomatic carotid artery stenosis, according to a meta-analysis of studies comparing the two options. The authors note, however, that there’s a lack of adequate data looking at these modalities in asymptomatic patients.
“Current management guidelines for the treatment of asymptomatic carotid stenosis are controversial,” write researchers led by Paola Moresoli (Jewish General Hospital, Montreal, Canada). “Although much of the controversy surrounds whether or not to revascularize asymptomatic patients, there is also substantial uncertainty on which revascularization procedure should be performed.”
According to American Heart Association guidelines, they write, most low-risk patients with > 70% internal carotid artery stenosis should undergo endarterectomy. Conversely, the US-based Society for Vascular Surgery, the UK National Institute for Health and Clinical Excellence, and the Heart and Stroke Foundation of Canada recommend that most patients should undergo endarterectomy, with stenting being reserved for clinical trials or for patients who are not operative candidates.
To help clarify the relative benefits of each procedure, the authors conducted a meta-analysis of five randomized trials comparing stenting versus surgery that included a total of 3,019 asymptomatic patients. Their findings were published online recently ahead of print in Stroke.
There was no significant difference between the two treatment modalities with respect to pooled incidences of any periprocedural stroke, nondisabling stroke, or stroke or death. In all cases, however, there was a trend toward increased risk with stenting. In addition, the possibility of a clinical significant increased risk for long-term stroke and the composite outcome of periprocedural stroke, death or MI, or long-term ipsilateral stroke with stenting could not be ruled out.
Outcomes of Stenting vs. Endarterectomy
|
|
Pooled Risk Ratio (95% CI) |
|
Any Periprocedural Stroke |
1.84 (0.99-3.40 |
|
Periprocedural Nondisabling Stroke |
1.95 (0.98-3.89) |
|
Any Periprocedural Stroke or Death |
1.72 (0.95-3.11) |
|
Long-term Stroke |
1.24 (0.76-2.03) |
|
Periprocedural Stroke, Death or MI, or Long-term Ipsilateral Stroke |
0.92 (0.70-1.21) |
“Much of this uncertainty” over how best to treat asymptomatic disease, Moresoli et al say, “stems from the clinical equipoise surrounding revascularization versus basic/best medical treatment/therapy” for this indication. Current guidelines are based on outdated data, and clinical trial evidence on stenting versus surgery in this context is inadequate, the authors note.
Still, they conclude: “Based on currently available data, CEA seems to be the safer and more efficacious treatment for asymptomatic carotid artery stenosis.”
Source:
Moresoli P, Habib B, Reynier P, et al. Carotid stenting versus endarterectomy for asymptomatic carotid artery stenosis: A systematic review and meta-analysis. Stroke. 2017;Epub ahead of print.
Disclosures:
Moresoli reports no relevant conflicts of interest.
