Short-, long-term stroke risks present major obstacle for carotid stenting

**Economopoulos K. Stroke. 2011;42;687-692.**

Issue: April 2011

A new meta-analysis has shown that the risk for stroke, as well as “stroke or death,” in patients who underwent carotid stenting was significantly higher during the long term and the short term vs. patients who underwent carotid endarterectomy.

The analysis featured data from 13 randomized trials, including CREST and ICSS, that accounted for 3,723 carotid endarterectomy (CEA) and 3,755 carotid artery stenting (CAS) procedures. Thirty-day outcomes were defined as short term, and those occurring at 1 year or later were defined as long term.

Researchers said during the short term, there was a significantly higher rate in CAS patients for stroke (OR=1.53; 95% CI, 1.23-1.91) and death or stroke (OR=1.54; 95% CI, 1.25-1.89), whereas risks for MI (OR=0.48; 95% CI, 0.30-0.78) and cranial nerve injury (OR=0.09; 95% CI, 0.05-0.16) were significantly lower in CAS patients.

During the long term, CAS was also linked with a statistically significant increase in risk for stroke (OR=1.37; 95% CI, 1.13-1.65) and death or stroke (OR=1.25; 95% CI, 1.06-1.48) compared with CEA. This long-term difference was particularly high in patients aged older than 68 years, whereas little difference was found in those who were younger.

The findings of the analysis, the researchers said, may improve the current understanding of the fine balance describing the CEA vs. CAS comparison.

“CAS represents a therapeutic option that necessitates careful selection of patients,” they said. “Taken as a whole, the outcomes of CEA seem superior to CAS, but there may be subgroups, particularly younger patients, in whom the results seem equivalent.” – by Brian Ellis

The results are similar to our comprehensive analysis published a few months back in the Archives of Neurology where we showed an increase in both short- and long-term events with CAS when compared with CEA. However, CEA was associated with increased risk of MI and cranial nerve injuries. Despite these results, the AHA/ASA guidelines for prevention of stroke recently updated their guidelines and elevated CAS for symptomatic patients at average or low risk of complications from a class IIa to a class I recommendation, driven by the results of the CREST trial.

In my opinion, CAS and CEA offer complementary options for patients with symptomatic carotid artery disease. While the debate on which technique is superior is ongoing for more than a decade, it is prudent to conclude that each technique has its strengths and limitations and the need of the hour is to individualize patient care based on the risk for MI vs. the risk for stroke. The debate is similar to CABG vs. PCI that has been around for 2 decades now. It is now increasingly clear that both techniques have their place and it is a matter of finding the right procedure for the right patients.

– Sripal Bangalore, MD

Director of Research, Cardiac Catheterization Laboratory

Assistant Professor of Medicine

New York University School of Medicine, New York

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