CAS, carotid endarterectomy similarly protective against stroke in asymptomatic patients
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In patients with asymptomatic severe carotid stenosis requiring intervention, there was no difference in 5-year stroke risk between those assigned carotid artery stenting and those assigned carotid endarterectomy.
For the ACST-2 trial, Alison Halliday, MS, professor of vascular surgery in the Nuffield Department of Surgical Science at the University of Oxford, and colleagues randomly assigned 3,625 patients with asymptomatic severe carotid stenosis recommended for intervention despite optimal medical therapy to receive CAS or carotid endarterectomy.
Results were presented at the European Society of Cardiology Congress and simultaneously published in The Lancet.
“Trials have shown that adding CEA approximately halves stroke rates over the next 5 years, and our question in this trial is, is CAS equally effective?” Halliday said during a press conference.
All patients had carotid artery stenosis of at least 60% on ultrasound but “do not have a recent stroke or other neurological symptoms,” Halliday said. “They are thought to need some carotid procedure, either CEA or CAS, but the doctor and the patient must be both substantially uncertain which of these to prefer in order to enter the trial.”
Thirty percent were women and approximately half were aged 70 years or older.
Procedural death or disabling stroke occurred in 1% of both groups and procedural nondisabling stroke occurred in 2% of both groups.
At 5 years, the Kaplan-Meier estimate of rates of fatal or disabling stroke was 2.5% in both groups (RR = 0.98; 95% CI, 0.64-1.48; P = .91), while the Kaplan-Meier estimate of rates of any stroke were 5.3% in the CAS group and 4.5% in the surgery group (RR = 1.16; 95% CI, 0.86-1.57; P = .33), according to the results.
“Both procedures approximately halved long-term risk from about 1% to about 0.5% per year,” Halliday said. “However, with stenting, there is a 1% to 2% excess risk of nondisabling stroke that left patients still able to carry out all of their previously usual activities.”
When the researchers performed a meta-analysis of all CAS vs. carotid endarterectomy trials, there was no difference between the procedures in risk for any nonprocedural stroke (RR = 1.11; 95% CI, 0.91-1.32; P = .21), with the results consistent in symptomatic and asymptomatic patients.
“For disabling and fatal stroke, CAS and CEA involve similar risks and similar benefits,” Halliday said at the press conference, noting the researchers plan to follow the patients for 10 years.
Reference:
Perspective
Back to TopT. Sloane Guy, MD
I do not think these results are surprising. In the modern era of carotid artery stenosis treatment, the complication rates are fairly low for both carotid stenting and endarterectomy. But this was a study that needed to be done, particularly because of the improving safety of the two procedures, to see if there was an advantage of one over the other in an asymptomatic patient population. It will help us make good decisions about treatment options.
For asymptomatic patients, the study shows these procedures are basically equivalent in terms of clinical outcomes. There are other issues related to patient access to high-quality stenting vs. surgery, and there may be unique clinical circumstances where one may be favored over another. For instance, carotid endarterectomy does not necessarily require high-powered blood thinners, whereas carotid stenting would. The results do not definitively favor one or the other. They show you can choose between the two and expect a relatively equal clinical outcome in most patients.
The endovascular world is continuing to develop, and I would like to think that the technology will continue to improve to the point where we could see an advantage to a catheter-based procedure. But this trial shows we are not quite there yet.
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Halliday A, et al. Hot Line: ACST-2. Presented at: European Society of Cardiology Congress; Aug. 27-30, 2021 (virtual meeting).
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