Carotid Artery Stenting Versus Carotid Endarterectomy for Asymptomatic Carotid Stenosis: A Propensity Score-Matched
Marco Colasurdo1, Matthew K McIntyre2, Jay Kakadiya3
1Department of Interventional Radiology, Oregon Health and Science University, Portland, Oregon, USA.
Insights
Carotid artery stenting (CAS) showed higher risks of stroke, mortality, and hemorrhage than carotid endarterectomy (CEA) in asymptomatic patients over five years. These findings suggest CEA may be a more favorable option for treating carotid stenosis.
Area of Science:
- Vascular Surgery
- Interventional Cardiology
- Neurology
Background:
- Carotid stenosis poses a significant risk of stroke.
- Carotid artery stenting (CAS) and carotid endarterectomy (CEA) are revascularization options.
- Limited head-to-head comparative data exists for asymptomatic carotid stenosis.
Purpose of the Study:
- To evaluate and compare real-world long-term outcomes of CAS versus CEA.
- To assess the safety and efficacy of CAS and CEA in asymptomatic carotid stenosis patients.
- To provide evidence for clinical decision-making in carotid revascularization.
Main Methods:
- Retrospective analysis of adults with asymptomatic carotid stenosis from January 2016 to December 2024 using the TriNetX US Collaborative Network.
- Exclusion of patients with prior stroke, TIA, hemorrhage, or posterior-circulation stenosis.
- 1:1 propensity score matching on demographics, comorbidities, and antithrombotic use, followed by Kaplan-Meier and Cox proportional hazards analyses for 5-year outcomes.
Main Results:
- Carotid artery stenting (CAS) was associated with a higher incidence of ischemic stroke (10.0% vs. 9.8%) and all-cause mortality (21.7% vs. 18.7%) compared to carotid endarterectomy (CEA) over 5 years.
- Intraparenchymal hemorrhage occurred more frequently after CAS (2.11% vs. 1.30%).
- Major bleeding rates were similar between CAS and CEA (12.10% vs. 11.88%).
Conclusions:
- Real-world data suggests CAS for asymptomatic carotid stenosis is linked to modestly higher rates of ischemic stroke, mortality, and intraparenchymal hemorrhage compared to CEA over a 5-year period.
- The findings indicate a potential benefit favoring CEA in this patient population.
- Further prospective studies are warranted to confirm these causal relationships.
Background And Objectives:
Carotid artery stenting (CAS) and carotid endarterectomy (CEA) are established revascularization strategies for carotid stenosis, yet evidence comparing them in asymptomatic populations remains limited. The Carotid Revascularization Endarterectomy versus Stenting Trial-2 used a parallel-arm design and did not provide a direct head-to-head comparison of CAS vs CEA. This study evaluates real-world long-term outcomes of CAS compared directly with those of CEA in asymptomatic carotid stenosis.
Methods:
Adults with asymptomatic carotid stenosis undergoing CAS or CEA between January 2016 and December 2024 were identified from the TriNetX US Collaborative Network. Patients with previous ischemic stroke, TIA, hemorrhage, or posterior-circulation stenosis were excluded. Propensity score matching (1:1) on demographics, comorbidities, and baseline antithrombotic medications yielded 5415 patients per cohort. Primary outcomes were all-cause mortality and ischemic stroke at 5 years; secondary outcomes included intraparenchymal hemorrhage and major bleeding. Kaplan-Meier analyses with log-rank testing and Cox proportional hazards models were used, with outcomes assessed at 6 months, 1, 3, and 5 years.
Results:
Ischemic stroke occurred in 10.0% of CAS vs 9.8% of CEA patients (cumulative probability 15.85% vs 14.07%; hazard ratio [HR] 1.179, 95% CI 1.045-1.329, P = .007). All-cause mortality was higher after CAS (21.70% vs 18.69%; HR 1.212, 95% CI 1.084-1.355, P = .001). Intraparenchymal hemorrhage was more frequent after CAS (2.11% vs 1.30%; HR 1.940, 95% CI 1.327-2.835, P < .001). Major bleeding rates were comparable (12.10% vs 11.88%; HR 1.130, P = .071). All standardized differences were <0.10 postmatching.
Conclusion:
In real-world practice, CAS for asymptomatic carotid stenosis was associated with modestly higher ischemic stroke, mortality, and intraparenchymal hemorrhage compared with CEA over 5 years, suggesting an association favoring CEA. Prospective studies are needed to establish definitive causal relationships.