Higher Stroke, Death Rates Persist With Carotid Stenting


Major Finding: The long-term risk of stroke is 48% higher after carotid stenting than after carotid endarterectomy, and the long-term risk of death or stroke is 24% higher.

Data Source: A meta-analysis of 13 recent randomized clinical trials comparing the two approaches.

Disclosures: One investigator reported receiving research grants from AstraZeneca, Bristol-Myers Squibb, Eisai, Ethicon, Heartscape, Sanofi Aventis, and the Medicines Company.

Carotid artery stenting carries higher intermediate- and long-term risks than does carotid endarterectomy, not just higher periprocedural risks, according to the largest, most comprehensive meta-analysis of evidence from randomized trials to date.

The safety and efficacy of carotid stenting as an alternative to endarterectomy are controversial. Studies have shown that stenting is more likely to cause periprocedural stroke, but data on longer-term outcomes are limited, said Dr. Sripal Bangalore of New York University, New York, and his associates.

They examined 13 randomized controlled trials that reported outcomes at 30 days or later and included 3,754 patients assigned to stenting and 3,723 to endarterectomy. The mean follow-up in the trials was 2.7 years.

In the short term, stenting was associated with a 31% increase in periprocedural death, MI, or stroke, compared with endarterectomy. Absolute rates of periprocedural death, MI, or stroke were 5.7% with stenting and 4.7% with endarterectomy, they said.

In the long term, the risk for that composite outcome plus later ipsilateral stroke or death was 19% higher after stenting than it was after endarterectomy. In comparison with endarterectomy, stenting carried a 38% higher risk of the composite outcome of periprocedural stroke or death plus later ipsilateral stroke, a 24% higher risk of the composite outcome of death or stroke, and a 48% increased risk of any stroke.

These increases in long-term risks were consistent across several subgroups: symptomatic or asymptomatic, low risk or high risk, American or non-American; and regardless of whether an embolic protection device was used, Dr. Bangalore and his colleagues wrote (Arch. Neurol. 2010 Oct. 11 [doi:10.1001/archneurol.2010.262]).

However, the rate of periprocedural MI was significantly lower with carotid stenting (0.3%) than with endarterectomy (1.2%). And stenting was associated with an 85% reduction in the risk of cranial nerve injury, all of which occurred in the periprocedural period.

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