Carotid artery stenting is as effective as carotid endarterectomy, study showsBMJ 2016; 352 doi: https://doi.org/10.1136/bmj.i1068 (Published 22 February 2016) Cite this as: BMJ 2016;352:i1068
Carotid artery stenting achieves a similarly low risk of death, stroke, and myocardial infarction (MI) to carotid endarterectomy in older patients with asymptomatic severe carotid stenosis, shows a randomised trial published in the New England Journal of Medicine that also showed similar rates of stroke and survival at five years.1
Carotid artery disease causes around 20% of strokes, and studies have shown that carotid endarterectomy can reduce the risk of stroke and death in people with severe carotid artery stenosis. Carotid artery stenting offers a potential alternative to surgery in patients at high risk of surgical complications, but its use in asymptomatic patients and in those at lower risk for surgery has been less clear.
Researchers randomly allocated 1453 patients aged 79 and under (mean age 67) who had asymptomatic carotid stenosis of 70-99% of the artery diameter to undergo carotid endarterectomy or carotid artery stenting with a device to capture and remove emboli. No participants were considered to be at high risk of operative complications. The trial, funded by Abbott Vascular, was designed to enrol 1658 patients, but recruitment was stopped early because of slow enrolment.
Patients were followed up for five years, and the researchers compared the rates of death, stroke, and MI among the stenting and surgery groups in the 30 days after the procedure, as well as the risk of ipsilateral stroke at one year.
They found similar rates of death, stroke, and MI at 30 days with stenting and with carotid endarterectomy (event rate 3.8% versus 3.4%; P=0.01 for non-inferiority). The risk of stroke or death within 30 days was 2.9% in patients who underwent stenting and 1.7% in those who had surgery (P=0.33).
From 30 days to five years after having their procedure 97.8% of patients given a stent remained free from ipsilateral stroke, compared with 97.3% in the endarterectomy group (P=0.21).
“In this multicentre trial involving patients 79 years of age or younger with asymptomatic severe carotid stenosis, carotid artery stenting was noninferior to carotid endarterectomy at one year with regard to . . . death, stroke and myocardial infarction within 30 days or ipsilateral stroke within 354 days after the procedure,” said the researchers, led by Kenneth Rosenfield, of Massachusetts General Hospital in Boston, USA.
The researchers acknowledged that a limitation of their study, which was designed a decade ago, was the lack of a comparison group treated with contemporary medical therapy. “Observational studies have shown that the annual risk of a stroke among asymptomatic patients is probably less than 1% per year with modern medical therapy,” they noted.