Protected carotid artery stenting in patients at high risk for carotid endarterectomy
Prasanna Venkatesh Kumar1, Aishwarya Lakshmi, Rakesh Shrivastava
1Overton Brooks VA Medical Center and Louisiana State University Health Sciences Center, Shreveport, LA, USA.
Insights
Carotid artery stenting (CAS) showed better six-month outcomes than high-risk carotid endarterectomy (CEA) in male veterans. CAS outcomes were similar to low-risk CEA, suggesting non-inferiority.
Area of Science:
- Vascular Surgery
- Interventional Cardiology
- Health Outcomes Research
Background:
- Carotid artery stenting (CAS) and carotid endarterectomy (CEA) are procedures to prevent stroke.
- The comparative effectiveness of CAS versus CEA, particularly in lower-risk patients, requires further investigation.
- Male veterans represent a specific population with unique health considerations for these interventions.
Purpose of the Study:
- To compare 30-day, six-month, and one-year outcomes of CAS and CEA in male veterans.
- To identify predictors of adverse outcomes following CAS and CEA.
- To clarify the role of CAS relative to both high-risk and low-risk CEA.
Main Methods:
- Retrospective analysis of 96 male veteran patients undergoing CAS (N=31) or CEA (N=65).
- Outcomes assessed included ipsilateral transient ischemic attack (TIA) or stroke, restenosis, revascularization, myocardial infarction (MI), and death at 30 days, six months, and one year.
- Patient risk stratification for CEA was performed.
Main Results:
- CAS patients were all high-risk for CEA. CEA patients included 76.9% high-risk and 23.1% low-risk.
- CAS demonstrated superior six-month outcomes compared to high-risk CEA (3.2% vs 18.5%, P=0.047).
- No significant outcome differences were observed between CAS and low-risk CEA. Number of risk factors and treatment group were predictors of early adverse events; ACE-inhibitor use predicted late adverse events.
Conclusions:
- Carotid artery stenting may be superior to high-risk carotid endarterectomy, particularly regarding six-month outcomes.
- Outcomes for CAS were comparable to low-risk CEA, suggesting CAS may be a non-inferior alternative.
- Further research into predictors of adverse events, such as ACE-inhibitor use, is warranted.
Objectives:
To compare the 30-day, six-month, and one-year outcomes of carotid artery stenting (CAS) and carotid endarterectomy (CEA) in male veterans, and to identify any predictors of adverse outcomes. CAS has been shown to be non-inferior to CEA in patients at high-risk for CEA. The outcome of CAS compared to low-risk CEA is less clear.
Methods:
Retrospective analysis of 96 consecutive patients who underwent CAS (N = 31) or CEA (N = 65). The cumulative 30-day, six-month, and one-year incidence of ipsilateral transient ischemic attack (TIA) or stroke, restenosis or reocclusion, need for target vessel revascularization, non-fatal myocardial infarction (MI), and death were compared.
Results:
All patients in the CAS group were at high risk for CEA. Among the CEA group, 50 (76.9%) were at high risk and the remaining 15 (23.1%) were considered to be at low risk. The cumulative incidence of adverse outcomes with CAS and CEA, respectively, at 30 days (3.2% vs 9.2%, P = ns), six months (3.2 vs 18.5%, P = 0.047), and one year (9.7% vs 18.5%, P = ns) favored CAS. This difference was primarily due to adverse events in the high-risk CEA patients. There was no significant difference in outcome between the CAS and low-risk CEA groups. The independent significant predictors for adverse outcomes within six months were the group (P = 0.047) and number of risk factors (P = 0.01). Interestingly, the use of angiotensin-converting enzyme inhibitors (ACE-I) predicted adverse outcomes within one year (P = 0.01).
Conclusion:
CAS may be superior to high-risk CEA with better six-month outcomes. The outcomes with CAS were not significantly different compared to low-risk CEA, suggesting that CAS may be non-inferior to low-risk CEA.