Carotid Revascularization

Posted by • July 2nd, 2010

Carotid-artery atherosclerosis is an important cause of ischemic stroke. Carotid endarterectomy has been established as effective treatment for both symptomatic patients and asymptomatic patients. Carotid-artery stenting is another option for treatment.

In a randomized comparison by Brott et al. of stenting and endarterectomy as treatment for carotid-artery stenosis, no significant difference was found in the rate of the composite primary end point of stroke, myocardial infarction, or death (7.2% and 6.8%, respectively; P=0.51).

Clinical Pearls

Was there any difference in the primary outcome between the carotid stenting and endarterectomy groups in this study?

Among patients with symptomatic or asymptomatic carotid stenosis in this study, there was no significant difference in the estimated 4-year rates of the primary end point between carotid-artery stenting and carotid endarterectomy (7.2% and 6.8%, respectively; hazard ratio for stenting, 1.11; 95% confidence interval [CI], 0.81 to 1.51; P=0.51).

What group of patients derived a benefit from stenting as compared to endarterectomy?

An interaction between age and treatment efficacy was detected (P=0.02), with a crossover at an age of approximately 70 years; carotid-artery stenting tended to show greater efficacy at younger ages and, carotid endarterectomy at older ages. Prespecified analyses did not show a modification of the treatment effect by symptomatic status (P=0.84) or by sex (P=0.34).

Morning Report Questions

Q: How did periprocedural events differ between groups in this study?

A: During the periprocedural period, the incidence of the primary end point was similar with carotid-artery stenting and carotid endarterectomy (5.2 and 4.5%, respectively; hazard ratio for stenting, 1.18; 95% CI, 0.82 to 1.68; P=0.38), although the rates of the individual end points differed between the stenting group and the endarterectomy group (death, 0.7% vs. 0.3%; P=0.18; stroke, 4.1% vs. 2.3%; P=0.01; myocardial infarction, 1.1% vs. 2.3%; P=0.03).

Q: What were the 4-year-rates of stroke or death in each group?

A: The 4-year rate of stroke or death was 6.4% in the stenting group as compared with 4.7% in the endarterectomy group (hazard ratio, 1.50; 95% CI, 1.05 to 2.15; P=0.03); the respective rates were 8.0% and 6.4% among symptomatic patients (hazard ratio, 1.37; 95% CI, 0.90 to 2.09; P=0.14) and 4.5% and 2.7% among asymptomatic patients (hazard ratio, 1.86; 95% CI, 0.95 to 3.66; P=0.07).

Figure 2. Primary End Point, According to Treatment Group.

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