CAS, CEA associated with similar long-term ipsilateral stroke rate

Carotid angioplasty and stenting led to a similar long-term rate of ipsilateral stroke when compared with carotid endarterectomy in patients with symptomatic and asymptomatic carotid stenosis. However, patients treated with endarterectomy had a significantly higher rate of fatal and nonfatal MI.

The single-center, randomized trial included 173 symptomatic and asymptomatic patients with high-grade carotid artery stenosis (>70%) of all surgical risks. The aim was to compare carotid angioplasty and stenting (CAS) with carotid endarterectomy (CEA) in terms of 10-year efficacy and durability outcomes. The investigators cited a paucity of long-term outcomes for these approaches in this patient population as motivation for conducting the study.

Eighty-seven patients died during follow-up. The most common cause was nonvascular disease, according to the results.

The treatment groups yielded similar rates of ipsilateral stroke in the treated artery (P>.05).

Clinicians assessed restenosis using sequential ultrasound, but only in the stenting group. The restenosis rate in this group was 3.3% and remained symptomatic.

The 10-year combined fatal or nonfatal MI risk was 27.5% in the symptomatic stenosis cohort compared with 11% for asymptomatic stenosis (HR=2.32; 95% CI, 1.298-4.146). Patients in the CEA group had higher 10-year combined fatal or nonfatal MI risk than those in the CAS group (HR=2.27; 95% CI, 1.35-3.816).

In an accompanying editorial, Robert D. Safian, MD, of the department of cardiovascular medicine and the Oakland University William Beaumont School of Medicine in the Beaumont Health System in Royal Oak, Mich., described the study as “somewhat enigmatic in some respects and compelling in others.”

“First, the original cohort of 189 patients consisted of 104 symptomatic patients (55%) and 85 asymptomatic patients (45%); the risk of periprocedural stroke was zero,” he wrote. “These are remarkably excellent results, particularly in symptomatic patients.”

Safian compared the results with those from other similar studies, including SAPPHIRE and CREST.

He said the findings in the current study, in terms of 10-year mortality, contrast sharply with those from the previous studies, and future studies should extend follow-up from 5 to 10 years.

“Although it is possible that [embolic protection devices] contributed to the risk of periprocedural stroke after CAS, this position would be difficult to defend in the context of the declining risk of stroke with contemporary proximal and distal [embolic protection devices] and also defies the current national coverage determination policy mandating the use of [embolic protection devices] in the United States,” he wrote.

CAS and CEA trials have reached “clinical equipoise” as approaches to treating revascularization, according to Safian.

“Our mission now should turn to study of medical therapies for carotid artery disease, and to noninvasive and invasive imaging tools to allow us to characterize plaque in the carotid circulation (and elsewhere),” he wrote. “Although revascularization will play an important role in alleviating stenosis and passivating plaque in the carotid arteries, systemic therapies will clearly be important, particularly for stabilizing plaque locally and in remote vascular beds.”

For more information:

Brooks WH. J Am Coll Cardiol Intv. 2014;7:163-168.

Safian RD. J Am Coll Cardiol Intv. 2014;7:169-170.

Disclosure: The researchers and Safian report no relevant financial disclosures.