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Temporal trends in short- and long-term outcomes after carotid interventions for symptomatic or asymptomatic
Carolijn J M de Bresser1, Robbert B M Wiggers1, Roos A M van Heeswijk1
1Department of Vascular Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands.
Insights
Short-term risks for carotid endarterectomy (CEA) and carotid artery stenting (CAS) have decreased, even in smaller patient groups. However, long-term death risk after CEA and stroke risk after CAS have increased, impacting intervention durability.
Area of Science:
- Vascular Surgery
- Interventional Cardiology
- Health Services Research
Background:
- Procedural risks for carotid endarterectomy (CEA) have declined in large studies.
- Trends in smaller cohorts, carotid artery stenting (CAS), and long-term outcomes require further investigation.
Purpose of the Study:
- To evaluate temporal trends in short-term and long-term outcomes for CEA and CAS.
- To assess if these trends apply to smaller patient cohorts.
Main Methods:
- Systematic review and meta-analysis of PubMed and EMBASE databases up to November 2024.
- Included studies with ≥100 adult patients undergoing CEA or CAS for carotid stenosis.
- Analyzed 30-day and long-term stroke or death risks, with separate analyses for cohorts <500 patients.
Main Results:
- Over 475,000 CEA and 209,000 CAS patients included.
- Short-term stroke/death risk decreased significantly for both CEA and CAS in symptomatic and asymptomatic patients.
- Long-term death risk after CEA increased by 26%, and long-term stroke risk after CAS increased by 30%.
Conclusions:
- Both CEA and CAS demonstrate improved short-term safety over time, including in smaller cohorts.
- Increased long-term risks for death (CEA) and stroke (CAS) raise concerns about intervention durability.
- Further research is needed to understand and mitigate these long-term risks.
Introduction:
In meta-analyses of large cohorts, a decline in procedural risks after carotid endarterectomy (CEA) was found. It remains unclear whether these trends extent to smaller cohorts, carotid artery stenting (CAS), and how long-term outcomes have evolved.
Patients And Methods:
PubMed and EMBASE were searched until 18 November 2024, for studies reporting on 100 or more adults undergoing CEA or CAS for symptomatic or asymptomatic carotid stenosis. Primary outcomes were 30-day and long-term risk of stroke or death. We performed separate analyses in smaller cohorts of < 500 patients.
Results:
291 studies reported 475,266 patients undergoing CEA (214,526 symptomatic, 260,740 asymptomatic) and 209,117 undergoing CAS (77,133 symptomatic, 131,984 asymptomatic). Short-term stroke or death after CEA declined 36% (RR = 0.64, 95% CI, 0.63-0.64) per 5-year later treatment midyear in symptomatic and 41% (RR = 0.59, 95% CI, 0.59-0.59) in asymptomatic patients, with consistent trends in smaller cohorts.For CAS, short-term risks declined 44% (RR = 0.56, 95% CI, 0.53-0.58) in symptomatic, and 27% (RR = 0.73, 95% CI, 0.71-0.74) in asymptomatic patients, with consistent trends in smaller cohorts. Long-term death risk after CEA increased 26% (RR = 1.26, 95% CI, 1.20-1.32) and 11% in smaller cohorts. Long-term stroke risk after CAS increased 30% (RR = 1.30, 95% CI, 1.17-1.43) and 44% in smaller cohorts.
Conclusions:
Short-term risks after CEA and CAS have decreased over time, also in smaller cohorts. Long-term death after CEA and stroke after CAS have increased. The increased long-term risk of death after CEA and stroke after CAS limits the durability of carotid interventions and warrants further scrutiny.
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