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11-10-2010 | Stroke | Article

Meta-analysis highlights need for individualized treatment of carotid stenosis

Abstract

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MedWire News: A meta-analysis shows that carotid artery stenting (CAS) is associated with a higher risk for periprocedural and long-term stroke compared with carotid endarterectomy (CEA), which is linked to an increased risk for myocardial infarction (MI).

"Thus, there is a need for identifying subsets of participants who are at low risk with CAS," Deepak Bhatt (VA Boston Healthcare System, Massachusetts, USA) and team write in the Archives of Neurology.

However, they note that CAS "is likely to be complementary to CEA," especially for patients at high risk for MI or surgical complications.

The meta-analysis includes 13 trials of CAS versus CEA, and incorporates the recent CREST (Carotid Revascularization Endarterectomy vs Stenting Trial) and ICSS (International Carotid Stenting Study) studies. Together, these provided data on 7477 patients.

Overall, patients undergoing CAS had a 31% increase in the risk for periprocedural outcomes (stroke, death, or MI), a 65% risk increase for death or stroke, and a 67% increase for any stroke relative to those who underwent CEA.

Conversely, patients undergoing CAS were 55% less likely to suffer MI and 85% less likely to suffer cranial nerve injury.

Follow-up in the included studies ranged from 4 to 65 months. After the periprocedural period, CAS was associated with poorer outcomes than CEA, report Bhatt et al. There was a 48% increase in the risk for any stroke, supported by the team's statistical analysis, which provided "firm evidence" for at least a 20% relative risk increase with CAS versus CEA.

In an accompanying editorial, Louis Caplan (Beth Israel Deaconess Medical Center, Boston, Massachusetts) and Thomas Brott (Mayo Clinic, Jacksonville, Florida, USA) noted that contemporary best medical treatment is also an option, especially for asymptomatic patients.

"Personalized treatment is fortunately en vogue today," they said.

They listed some of the many factors with a bearing on which therapeutic approach is best for which patient, including related symptoms, the location and nature of the stenosis, comorbidities, and patient preferences.

"Care of individual patients will always rest in the hands of a trained experienced doctor on one end of a stethoscope and a patient on the other end," concluded Caplan and Brott.

"Trials can enlighten that encounter but never replace it."

MedWire (www.medwire-news.md) is an independent clinical news service provided by Current Medicine Group, a trading division of Springer Healthcare Limited. © Springer Healthcare Ltd; 2010

By Eleanor McDermid