Excess stroke risk with CAS versus CEA may be limited to elderly patients
MedWire News: Carotid artery stenting (CAS) may be as safe as carotid endarterectomy (CEA) in patients with symptomatic stenosis who are younger than 70 years, says the Carotid Stenting Trialists' Collaboration.
The team conducted a meta-analysis of data from three major trials of CAS versus CEA, including the recent International Carotid Stenting Study (ICSS), giving a total of 3433 patients.
Overall, they found that 8.9% of patients who underwent CAS suffered stroke or died during the first 120 days after randomization (intention-to-treat analysis), compared with 5.8% of those who underwent CEA, giving a risk ratio of 1.53 and a 3.2% absolute risk difference.
This increase was driven by the 1.99-fold increase in risk for nondisabling stroke; rates for fatal and disabling stroke, and all-cause death, were similar in each group.
But in patients younger than 70 years, treatment allocation did not affect stroke and death risk, with rates of 5.8% and 5.7% in the CAS and CEA groups, respectively.
In contrast, the corresponding rates in patients aged 70 years or older were 12.0% versus 5.9%, equating to a 2.04-fold risk increase. This age group also had a significant 1.78-fold increased risk for disabling stroke or death if they underwent CAS, at 7.0% versus 3.9% with CEA.
The influence of age on stroke or death risk after CAS appeared to be linear, note Martin Brown (University College London, UK) and colleagues. They say this supports the possibility of a biologic mechanism underlying the association.
"Results from clinical trials and previous meta-analyses of summary data have not justified any shift away from endarterectomy as the treatment of choice for symptomatic carotid stenosis," the team writes in The Lancet.
Therefore, current guidelines advise stenting only in very specific patient groups, such as those with surgically inaccessible lesions or with recurrent stenosis after endarterectomy.
"Our findings suggest that stenting might also be a viable alternative to endarterectomy in younger patients, in whom surgery could otherwise be undertaken without increased risk," Brown et al conclude.
However, they caution that "some uncertainty" remains about restenosis rates after CAS versus CEA.
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By Eleanor McDermid