Mixed results documented for carotid artery stenting vs. carotid endarterectomy

Bangalore S. Arch Neurol. 2010;doi:10.1001/archneurol.2010.262.

Carotid artery stenting when compared with carotid endarterectomy was associated with an increased risk for periprocedural and intermediate- to long-term outcomes, despite reducing periprocedural MI and cranial nerve injury, according to data published online by the Archives of Neurology.

In the study, researchers conducted PubMed, Embase and Cochrane Central Register of Controlled Trials searches through May for randomized clinical trials comparing carotid artery stenting (CAS) with carotid endarterectomy (CEA) for carotid artery disease. All eligible trials reported 30-day or longer-term outcomes and were randomized clinical trials of participants with or without symptomatic carotid artery stenosis comparing CAS with CEA, with or without an embolic protection device.

In the 13 randomized clinical trials found (7,477 patients), CAS correlated with an increased risk of outcomes of death, MI or stroke (OR=1.31; 95% CI, 1.08-1.59), a 65% increase in death or stroke and a 67% increase in any stroke when compared with CEA. Researchers also reported a risk reduction in the risk for MI (55%) and cranial nerve injury (85%) for those undergoing CAS.

“In this largest and most comprehensive meta-analysis of the available evidence from randomized trials to date … CAS was associated with a significant increase in the risk of short- and long-term outcomes compared with CEA,” the researchers concluded. “This was confirmed by a trial sequential analysis in which the monitoring boundaries were crossed, suggesting a relative risk increase of at least 20% with stenting. However, CAS was associated with a significant reduction of periprocedural MI or cranial nerve palsies. Thus, there is a need for identifying subsets of participants who are at low risk with CAS.”

One of the problems I have with this study is that it included two trials that are really old and were done without current equipment or practice (Alberts et al and Naylor et al). Both of these had very negative results for carotid stenting and both had a lot to do with changing how we practice carotid stenting. So I don’t know if it makes a lot of sense to average the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) trial and International Carotid Stenting Study (ICSS) – two trials completed this year – with two that were done roughly ten years ago. While I know the emphasis of this study is on completeness in terms of it including the most number of trials in a meta-analysis, it included trials that I feel weakens this study as a whole.

And, at the end of the day, this paper doesn’t help me decide which patients are better for stenting and which are better for surgery. What this paper confirms for me is that there is relative balance between the two procedures and that there is going to be a physician necessary to help guide the patient one way or the other for their treatment. It’s also important to remember that medical therapy is a valid option. There are many patients who are going to be better treated by continuing their medical therapy because of the risk of stroke or heart attack with the two procedures.

– Chris White, MD

System Chair, Cardiovascular Disease

Ochsner Clinic, New Orleans

*Dr. White reports serving as the national principal investigator for the recently closed carotid-stenting trial CABANA (sponsored by Boston Scientific).

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