Stroke/Death Rates Following Carotid Artery Stenting and Carotid Endarterectomy in Contemporary Administrative
K I Paraskevas1, E L Kalmykov2, A R Naylor2
1St. George's Vascular Institute, St. George's Healthcare NHS Trust, London, UK.
Insights
Carotid artery stenting (CAS) shows higher stroke/death rates than carotid endarterectomy (CEA) in recent data. Outcomes often exceed American Heart Association (AHA) thresholds, with no evidence of improved safety over time for CAS.
Area of Science:
- Vascular Surgery
- Interventional Cardiology
- Health Services Research
Background:
- Randomized trials indicate higher stroke/death rates for carotid artery stenting (CAS) compared to carotid endarterectomy (CEA).
- Despite trial data, 2011 American Heart Association (AHA) guidelines expanded CAS indications, influenced by specific trials and industry-sponsored registry outcomes.
- Contemporary administrative dataset registries provide crucial insights into real-world procedural risks.
Purpose of the Study:
- To compare stroke/death rates between CAS and CEA in contemporary registries.
- To evaluate if CAS stroke/death rates align with established AHA risk thresholds.
- To investigate trends in procedural risk for CAS and CEA over time.
Main Methods:
- Systematic search of PubMed/Medline, Embase, and Cochrane databases (Jan 2008-Feb 2015).
- Inclusion of administrative dataset registries reporting outcomes for both CEA and CAS.
- Adherence to PRISMA statement recommendations for systematic reviews.
Main Results:
- Analysis of 21 registries with over 1.5 million procedures.
- Significantly higher stroke/death rates post-CAS compared to CEA in 52% of registries for asymptomatic and 61% for symptomatic patients.
- CAS outcomes exceeded AHA thresholds in 43% of registries for asymptomatic and 72% for symptomatic patients; procedural risk surpassed 10% in 28% of registries for symptomatic patients.
Conclusions:
- Contemporary registries indicate persistently higher stroke/death rates with CAS versus CEA.
- CAS procedural risks frequently exceed recommended AHA thresholds.
- No evidence supports a sustained decrease in procedural risk for CAS over the study period.
Background:
Randomised trials have reported higher stroke/death rates after carotid artery stenting (CAS) versus carotid endarterectomy (CEA). Despite this, the 2011 American Heart Association (AHA) guidelines expanded CAS indications, partly because of the Carotid Revascularization Endarterectomy versus Stenting Trial, but also because of improving outcomes in industry sponsored CAS Registries. The aim of this systematic review was: (i) to compare stroke/death rates after CAS/CEA in contemporary dataset registries, (ii) to examine whether published stroke/death rates after CAS fall within AHA thresholds, and, (iii) to see if there had been a decline (over time) in procedural risk after CAS/CEA.
Methods:
PubMed/Medline, Embase, and Cochrane databases were systematically searched according to the recommendations of the PRISMA statement from January 1, 2008 until February 23, 2015 for administrative dataset registries reporting outcomes after both CEA and CAS.
Results:
Twenty-one registries reported outcomes involving more than 1,500,000 procedures. Stroke/death after CAS was significantly higher than after CEA in 11/21 registries (52%) involving "average risk for CEA" asymptomatic patients and in 11/18 registries (61%) involving "average risk for CEA" symptomatic patients. In another five registries, CAS was associated with higher stroke/death rates than CEA for both symptomatic and asymptomatic patients, but formal statistical comparison was not reported. CAS was associated with stroke/death rates that exceeded risk thresholds recommended by the AHA in 9/21 registries (43%) involving "average risk for CEA" asymptomatic patients and in 13/18 registries (72%) involving "average risk for CEA" symptomatic patients. In 5/18 registries (28%), the procedural risk after CAS in "average risk" symptomatic patients exceeded 10%.
Conclusions:
Data from contemporary administrative dataset registries suggest that stroke/death rates following CAS remain significantly higher than after CEA and often exceed accepted AHA thresholds. There was no evidence of a sustained decline in procedural risk after CAS.
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