Comparative Effectiveness of Carotid Stenting to Medical Therapy Among Patients With Asymptomatic Carotid Stenosis
Salomeh Keyhani1, Eric M Cheng2, Katherine Hoggatt1
1Department of Medicine, UCSF Division of General Internal Medicine, San Francisco Veterans Affairs Medical Center, CA (S.K., K.H.).
Insights
Carotid artery stenting (CAS) showed no significant difference in stroke risk compared to medical therapy (MT) for asymptomatic carotid stenosis over five years in older male veterans.
Area of Science:
- Vascular Surgery
- Neurology
- Geriatric Medicine
Background:
- Asymptomatic carotid stenosis poses a stroke risk.
- No prior trials directly compared carotid artery stenting (CAS) with medical therapy (MT).
- Effectiveness of CAS versus MT for asymptomatic carotid stenosis remains under investigation.
Purpose of the Study:
- To compare the effectiveness of CAS and MT in preventing stroke in patients with asymptomatic carotid stenosis.
- To evaluate the 5-year risk of fatal and nonfatal stroke in patients undergoing CAS versus MT.
Main Methods:
- Retrospective cohort study of 219,979 US Veterans aged 65+ with asymptomatic carotid stenosis (2005-2009).
- Comparison of a sample of 551 patients receiving CAS with 2509 patients receiving MT.
- Utilized target trial methodology with 5-year follow-up, employing weighted Kaplan-Meier curves and competing risks analysis.
Main Results:
- The 5-year risk of fatal and nonfatal stroke was similar between CAS (6.9%) and MT (7.1%), with a nonsignificant risk difference.
- Perioperative stroke or death within 30 days of CAS was 2.2%.
- Competing risks analysis for death did not reveal a significant difference between CAS and MT.
Conclusions:
- In this cohort of older male adults, CAS did not demonstrate a significant benefit over MT for treating asymptomatic carotid stenosis.
- Further research in diverse populations is necessary to validate these findings.
- The study highlights the need for comparative effectiveness research in vascular interventions.
Background:
No completed trials have compared carotid artery stenting (CAS) to medical therapy (MT). We examined the effectiveness of CAS compared with MT in patients with asymptomatic carotid stenosis.
Methods:
We conducted a retrospective cohort study of 219 979 Veterans ≥65 years who received carotid imaging for asymptomatic carotid stenosis between 2005 and 2009 in the US Veterans Health Administration. We constructed a sample of patients who received MT (n=2509) and comparable patients who received CAS (n=551) and followed them for 5 years. Using target trial methodology, we computed weighted Kaplan-Meier curves and estimated the risk of fatal and nonfatal stroke in each group over 5 years of follow-up. We also estimated the cumulative incidence functions for fatal and nonfatal stroke accounting for nonstroke deaths as competing risks.
Results:
Five hundred fifty-one patients received CAS, and 2509 patients received MT. The observed rate of stroke or death (perioperative complications) within 30 days in the CAS arm was 2.2%. Using the target trial methodology, the 5-year risk of fatal and nonfatal stroke was similar among patients assigned to CAS (6.9%) compared with patients assigned to MT (7.1%; risk difference, -0.1% [95% CI, -2.6% to 2.7%]). In an analysis that incorporated the competing risk of death, the risk difference between the two arms remained nonsignificant (risk difference, -1.5% [95% CI, -3.0% to 0.3%]).
Conclusions:
In this sample of older male adults, we found no difference between MT and CAS in the treatment of asymptomatic carotid stenosis. Future studies in other settings are needed to confirm these findings.
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