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Endarterectomy Versus Stenting for Stroke Prevention

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Endarterectomy Versus Stenting for Stroke Prevention Open Access Review Stroke Vasc Neurol: first published as 10.1136/svn-2018-000146 on 24 February 2018. Downloaded from Endarterectomy versus stenting for stroke prevention A Ross Naylor To cite: Naylor AR. ABSTRACT stenosis,1 2 using the NASCET method for Endarterectomy versus stenting The European Society for Vascular Surgery (ESVS) has measuring carotid stenosis severity.2 Subgroup for stroke prevention. Stroke recently prepared updated guidelines for the management analyses suggested that it was possible to iden- and Vascular Neurology 2018;0: of patients with symptomatic and asymptomatic e000146. doi:10.1136/svn- tify certain imaging/clinical features that atherosclerotic carotid artery disease, with specific 2018-000146 were associated with a higher risk of stroke on reference to the roles of best medical therapy, carotid BMT.3 Clinical features of increased benefit endarterectomy (CEA) and carotid artery stenting (CAS). In conferred by CEA include: increasing age Received 15 January 2018 symptomatic patients, there is a drive towards performing Accepted 4 February 2018 carotid interventions as soon as possible after onset of (especially patients aged >75 years), recency symptoms. This is because it is now recognised that the of symptoms, male sex, hemispheric versus highest risk period for recurrent stroke is the first 7–14 ocular symptoms, cortical versus lacunar 3 days after onset of symptoms. The guidelines advise that stroke and increasing medical comorbidities. there is a role for both CEA and CAS, but the levels of Imaging features associated with an increased evidence are slightly lower for CAS than for CEA. This is risk of stroke on medical therapy include: because 30-day risks of death/stroke in the randomised irregular versus smooth plaques, increasing controlled trials (RCTs) were significantly higher than stenosis severity (but not subocclusion), after CEA (especially in the first 7–14 days after onset contralateral occlusion, tandem intracranial of symptoms) and there are concerns that the results disease and a failure to recruit the intracra- obtained in the RCTs may not be generalisable into routine nial collateral circulation.3 clinical practice. In asymptomatic patients, the 2018 ESVS guidelines were the first to recommend that CEA/ CAS should be targeted into a smaller cohort of patients CEA versus CAS in recently symptomatic patients who may be ‘higher risk for stroke’ on medical therapy. 30-day outcomes As with symptomatic patients, the ESVS guidelines advise Nine RCTs recruited symptomatic patients that there is a potential role for both CEA and CAS, but the only,4–12 while five randomised both symp- levels of evidence are again slightly lower for CAS than for tomatic and asymptomatic patients between http://svn.bmj.com/ CEA. This is because 30-day risks of death/stroke in the CEA and carotid artery stenting (CAS).13–17 two largest RCTs, which used credentialed (experienced The most influential national/international CAS practitioners), were only just within the accepted 3% RCTs comparing CEA with CAS in sympto- risk threshold and there remain concerns that the results matic patients include: the Endarterectomy obtained in RCTs may not be generalisable into routine Versus Angioplasty in Patients with Symp- clinical practice. tomatic Severe Carotid Stenosis (EVA-3S) trial, the Stent-Protected Angioplasty versus on September 24, 2021 by guest. Protected copyright. SYMPTOMATIC PATIENTS Carotid Endarterectomy (SPACE) study, the Background International Carotid Stenting Study and Patients are traditionally considered ‘recently the Carotid Revascularisation versus Stenting symptomatic’ if they have suffered a carotid Trial (CREST).8 9 11 18 The principle 30-day territory transient ischaemic attack or stroke endpoints for these four RCTs are detailed in within the preceding 6 months. In the 1980s, table 1. there was controversy as to whether carotid Table 2 details ORs (95% CIs) for 30-day endarterectomy (CEA) conferred any benefit death/stroke in the four main RCTs, where over best medical therapy (BMT) in patients only the symptomatic patients randomised with an ipsilateral carotid stenosis. Two land- within CREST were included within the mark randomised controlled trials (RCTs), meta-analysis. the European Carotid Surgery Trial (ECST) The Carotid Stent Trialists Collabora- The Leicester Vascular Institute, and the North American Symptomatic tion (CSTC) have undertaken a number of Glenfield Hospital, Leicester, UK Carotid Endarterectomy Trial (NASCET), subgroup analyses to determine factors asso- Correspondence to determined that CEA conferred significant ciated with poorer outcomes after CAS and Professor A Ross Naylor; benefit over BMT in patients with an ipsilat- CEA, which may influence how individual ross. naylor@ uhl- tr. nhs. uk eral 50%–99% internal carotid artery (ICA) symptomatic patients are treated. Naylor AR. Stroke and Vascular Neurology 2018;0:e000146. doi:10.1136/svn-2018-000146 1 Open Access Stroke Vasc Neurol: first published as 10.1136/svn-2018-000146 on 24 February 2018. Downloaded from Table 1 30-day risks following CEA and CAS in trials that randomised >500 recently symptomatic patients into EVA-3S, SPACE, International Carotid Stenting Study (ICSS) and CREST8 9 11 18 EVA-3S8 SPACE9 ICSS11 CREST*18 CEA CAS CEA CAS CEA CAS CEA CAS 30-day risks (n=262) (n=261) (n=589) (n=607) (n=857) (n=853) (n=653) (n=668) Death 1.2% 0.8% 0.9% 1.0% 0.8% 2.3% Any stroke 3.5% 9.2% 6.2% 7.2% 4.1% 7.7% 3.2% 5.5% Death/any stroke 3.9% 9.6% 6.5% 7.4% 4.7% 8.5% 3.2% 6.0% Death/disabling stroke 1.5% 3.4% 3.8% 5.1% 3.2% 4% Death/stroke/MI 5.2% 8.5% 5.4% 6.7% Cranial nerve injury 7.7% 1.1% 5.3% 0.1% 5.1% 0.5% *Only includes symptomatic patients from CREST. CAS, carotid artery stenting; CEA, carotid endarterectomy; CREST, Carotid Revascularisation versus Stenting Trial; EVA-3S, Endarterectomy Versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis; MI, myocardial infarction; SPACE, Stent-Protected Angioplasty versus Carotid Endarterectomy. CAS operator experience Compared with CAS patients aged <60 years, performing In EVA-3S, SPACE and ICSS, the 30-day rate of death/ CAS in patients aged 70–74 years was associated with a stroke was not influenced by lifetime CAS practitioner significant increase in 30-day death/stroke (OR 4.01 stenting experience (P=0.8). However, the 30-day rate (95% CI 2.19 to 7.32)). In CAS patients aged >80 years of death/stroke was significantly higher in symptomatic (compared with CAS patients<60 years), the 30-day risk patients who were treated by CAS practitioners with a low of death/stroke was increased by 4.15 (95% CI 2.20 to annual CAS volume (≤3 procedures per annum; 30-day 7.84).20 death/stroke=10.1%; adjusted risk ratio=2.30 (95% CI Compared with CEA, 30-day rates of death/stroke were 1.36 to 3.87)), versus intermediate in-trial CAS volumes no different after CAS in recently symptomatic patients (3–6 procedures per annum; 30-day death/stroke=8.4%; aged <70 years of age. However, there was a progressive adjusted risk ratio=1.93 (95% CI 1.14 to 3.27)), compared increase in the risk of death/stroke after CAS (compared with patients treated by higher annual in-trial volume with CEA) which became significant at age 70–74 (OR practitioners (>6 procedures per year; 30-day death 2.09 (95% CI 1.32 to 2.32)), increasing to an OR of 2.43 stroke=5.1%).19 (95% CI 1.35 to 4.38) for CAS patients aged >80 years.20 Effect of age in recently symptomatic patients Recency of symptoms http://svn.bmj.com/ The CSTC pooled data from EVA-3S, SPACE, ICSS and There is now a worldwide drive towards performing CREST, regarding the effect of increasing age on 30-day carotid interventions as soon as possible after onset of death/stroke after CEA and CAS.20 There was no evidence symptoms. This is because evidence suggests that the risk of any association between increasing patient age and of stroke in the first 7–14 days after onset of symptoms an increased risk of death/stroke after CEA. However, is significantly higher than previously thought, while increasing age was associated with increasing proce- delays to CEA are associated with significant reductions dural risks in symptomatic patients undergoing CAS. in the benefit conferred by CEA.3 The CSTC undertook on September 24, 2021 by guest. Protected copyright. an individual patient meta-analysis of outcomes, stratified for the time delay between symptom onset and under- Table 2 ORs (95% CIs) for 30-day death/stroke for CEA going CEA/CAS.21 Patients undergoing CAS within 0–7 versus CAS in EVA-3S, SPACE, ICSS and CREST* days after symptom onset were significantly more likely Trial OR (95% CI) to suffer a perioperative stroke (9.4%), compared with CEA (2.8%) (OR 3.4 (95% CI 1.01 to 11.8)). Patients EVA-3S8 0.38 (0.16 to 0.84) 9 undergoing CAS within 8–14 days after symptom onset SPACE 0.89 (0.55 to 1.42) were also significantly more likely to suffer a periopera- 11 ICSS 0.53 (0.35 to 0.80) tive stroke (8.1%) compared with CEA (3.4%) (OR 2.4 CREST*18 0.52 (0.29 to 0.92) (95% CI 1.0 to 5.7)).21 Meta-analysis 0.59 (0.42 to 0.81) Late outcomes after CEA/CAS in symptomatic patients *Only symptomatic patients from CREST were included. Late ipsilateral stroke CAS, carotid artery stenting; CEA, carotid endarterectomy; Each of the four largest RCTs have shown that once the CREST, Carotid Revascularisation versus Stenting Trial; EVA-3S, Endarterectomy Versus Angioplasty in Patients with Symptomatic perioperative period has elapsed, late rates of ipsilateral Severe Carotid Stenosis; SPACE, Stent-Protected Angioplasty stroke were no different to CEA, indicating that CAS was versus Carotid Endarterectomy.
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