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Carotid endarterectomy surpasses stenting in elderly, asymptomatic patients

Key clinical point: Carotid stenting produced worse outcomes than endarterectomy in asymptomatic patients aged 75-79 years.

Major finding: Among asymptomatic patients aged 75-79 years, carotid stenting produced 190% more adverse outcomes than did carotid endarterectomy.

Study details: A pooled analysis of data from the CREST and ACT 1 studies that included 2,544 total asymptomatic patients with severe carotid artery stenosis.

Disclosures: Dr. Voeks reported no disclosures.


Voeks JH al. Stroke. 2020 Feb 12;51[suppl 1], Abstract 70.


The role for carotid intervention in asymptomatic patients with severe carotid stenosis, usually defined as a stenosis that obstructs at least 70% of the carotid lumen, is controversial right now because intensive medical management has not been compared with invasive treatments, such as carotid endarterectomy and carotid stenting, for well over a decade. New drugs and new regimens have become treatment options for patients with advanced atherosclerotic carotid artery disease, and this has returned us to a state of equipoise for medical versus interventional management. That’s the premise behind CREST 2 (Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial), which is comparing medical treatment against endarterectomy and against carotid stenting in a randomized study. The results may be available in 2021.

It’s not surprising to see that carotid endarterectomy (CEA) outperformed carotid artery stenting (CAS) in this pooled analysis. We have already seen evidence that CAS does not perform as well as CEA in older patients with symptomatic carotid artery disease, likely because older patients have more fragile and torturous blood vessels that make CAS more challenging and raise the potential for more adverse events. The new data reported by Dr. Voek should make people pause when considering CAS for asymptomatic patients who are in their 70s or older, but until we have more contemporary data, medical management is another reasonable option.

The new findings are very important for helping patients and their families make informed decisions. CAS is often perceived as the safer option for older patients because it is less traumatic and invasive than CEA. The data that Dr. Voeks reported show once again that this intuitive impression about CAS in the elderly is belied by the evidence. But the findings also require cautious interpretation because they came from a post hoc, subgroup analysis.

Mai N. Nguyen-Huynh, MD , is a vascular neurologist with Kaiser Permanente Northern California in Oakland. She had no relevant disclosures. She made these comments in an interview.