ICSS and EXACT/CAPTURE: More questions than answers

Area of Science:

• Vascular Surgery
• Interventional Cardiology
• Clinical Trials

Background:

• Conflicting conclusions from the International Carotid Stenting Study (ICSS) and a high-risk patient registry regarding carotid artery stenting (CAS) outcomes.
• Need for re-evaluation of CAS efficacy and safety in light of new trial data.

Purpose of the Study:

• To evaluate the impact of recent trials on the current status of carotid artery stenting (CAS).
• To clarify the evidence base for CAS in symptomatic patients with carotid artery stenosis.

Main Methods:

• Analysis of 30-day procedural risks from the ICSS and a 'super' registry.
• Review of existing evidence and anticipated meta-analyses of individual patient data from major randomized trials (SPACE, EVA-3S, ICSS, CREST).

Main Results:

• CAS is supported for selected 'high risk for CEA' non-octogenarian symptomatic patients with acceptable procedural risk and rapid intervention.
• No Level I evidence supports routine CAS for 'standard risk' symptomatic patients.
• Meta-analyses may identify specific subgroups benefiting from CAS.

Conclusions:

• Expedited carotid endarterectomy (CEA) is recommended for the majority of standard-risk symptomatic patients.
• Practitioners offering CAS to standard-risk patients must maintain audited 30-day death/stroke risks below 6% and ensure rapid intervention (within 2 weeks).
• Delaying intervention to reduce procedural risk offers minimal patient benefit.