CAS Compared to CEA for Risk of Stroke and Death

December 13, 2010—The Society for Vascular Surgery announced that Marc L. Schemerhorn, MD, et al reported findings from an evaluation of mortality and stroke following carotid artery stenting (CAS) versus carotid endarterectomy (CEA) stratified by medical high-risk criteria. The study was published in the Journal of Vascular Surgery (2010;52:1497–1504).

The investigators noted that to meet reimbursement criteria, candidates for CAS must either be high-risk surgical patients or be enrolled in a critical trial and that reimbursement criteria may bias comparisons of CAS and CEA.

“We gathered data from the Nationwide Inpatient Sample between 2004 and 2007 and identified 56,564 CAS patients and 482,394 CEA patients, all who had a diagnosis of carotid artery stenosis,” commented Dr. Schemerhorn. “Medical high-risk criteria were identified for each patient including those undergoing a coronary artery bypass and/or valve repair (CABG/V) during the same admission. Symptom status was defined by history of stroke, transient ischemic attack, and/or amaurosis fugax. The primary outcome was postoperative death, stroke, and combined stroke or death stratified by high-risk versus non–high-risk status and symptom status.”

The investigators reported that in high-risk and low-risk patients, mortality was higher after CAS than CEA, and stroke was higher in both risk groups after CAS. Patients undergoing CAS were more likely to be symptomatic than those undergoing CEA (13.1% vs 9.4%). Combined stroke or death was higher after CAS for both high-risk patients (asymptomatic, 1.5% vs 1.2%; symptomatic, 14.4% vs 6.9%) and non–high-risk patients (asymptomatic, 1.8% vs 0.6%; symptomatic, 11.8% vs 4.9%).

CABG/V was performed less commonly with CAS than CEA (2.8% vs 4%). The combined stroke or death for patients undergoing CABG/V during the same admission was similar for CAS and CEA (4.8% vs 3.2%). Multivariate predictors of combined stroke or death adjusted for age and gender included CAS vs CEA (odds ratio [OR], 2.4; symptom status (OR, 6.8); high risk (OR, 1.6); and earlier year of procedure (OR, 1.1).

According to SVS, Dr. Schemerhorn stated that even though this study found that CAS has a higher risk of stroke and death than CEA after adjustment for medical high-risk criteria, further analysis with prospective assessment of risk factors is needed to guide appropriate patient selection for CEA and CAS in the general population.

“As more randomized trials compare the efficacy of CAS relative to CEA, additional population-based analyses with well-defined high-risk criteria are needed to be certain that acceptable results are obtainable in the general population,” concluded Dr. Schemerhorn. “Further work also is needed to define the appropriate role of either revascularization method in those with specified high-risk criteria.”