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Stroke, mortality higher with carotid artery stenting vs. endarterectomy
Rates of stroke and mortality after carotid artery stenting are significantly higher compared with those after carotid endarterectomy, and the rates frequently exceed established risk thresholds, according to results of a recent systematic review.
The researchers collected data from 21 registries within the PubMed, Medline, Embase and Cochrane databases on outcomes after carotid artery stenting (CAS) and carotid endarterectomy (CEA) between 2008 and February 2015. The analysis included more than 1.5 million procedures divided into the following subgroups: asymptomatic patients at average risk for CEA, symptomatic patients at average risk for CEA, asymptomatic patients at high risk for CEA and symptomatic patients at high risk for CEA.
Average-risk patients
Across 21 registries reporting outcomes in asymptomatic, average-risk patients, 52% of registries reported significantly higher stroke and mortality rates after CAS compared with CEA. An additional 24% of the registries indicated that CAS was associated with significantly higher stroke/mortality rates but did not include formal statistical comparisons. Rates of stroke and mortality exceeded the 3% threshold recommended by the American Heart Association and American Stroke Association in 43% of registries. According to the researchers, CEA was associated with stroke/mortality rates above the recommended risk threshold in 5% of registries.
Among 18 registries reporting outcomes in symptomatic, average-risk patients, 61% indicated significantly higher stroke/mortality rates following CAS compared with CEA. An additional 28% reported higher rates after CAS but did not include formal statistical comparisons, the researchers wrote. The observed rates exceeded the 6% risk threshold for in-hospital/30-day stroke or mortality recommended by the AHA/ASA for this population in 72% of registries. Stroke/mortality rates exceeded this threshold among those treated with CEA in 11% of the evaluated registries.
High-risk patients
Three registries reported outcomes among asymptomatic, high-risk patients. CAS was associated with higher stroke/mortality rates compared with CEA in two of the three registries, although one of the two did not include a formal statistical comparison, the researchers wrote. The AHA/ASA-recommended 3% risk threshold for in-hospital/30-day stroke or mortality was exceeded for both CEA and CAS in one registry.
Among three registries reporting outcomes in symptomatic, high-risk patients, two indicated significantly higher stroke/mortality rates after CAS compared with CEA, whereas the third registry indicated higher rates with CAS but did not include a formal statistical comparison. All three registries reported stroke/mortality rates exceeding the AHA/ASA risk threshold of 6% among those treated with CAS. Among patients who received CEA, the risk threshold was exceeded in two registries.
“While CAS has advanced significantly over the last decade, evidence suggests that most contemporary administrative dataset registries (predominantly sourced from the USA) still report procedural stroke/death rates following CAS that are significantly higher (when compared with CEA), particularly in ‘average risk for CEA’ symptomatic patients,” the researchers wrote. “This systematic review found no evidence that procedural risks after CAS ‘in the real world’ have diminished with time.” – by Adam Taliercio
Disclosure: The researchers report no relevant financial disclosures.