September 25, 2019
Findings Published From Review and Analysis of RCTs Comparing CEA and CAS
September 26, 2019—Andrew J. Batchelder, MD, Athanasios Saratzis, MD, and A. Ross Naylor, MD, published findings of an overview of primary and secondary analyses from 20 randomized controlled trials (RCTs) comparing carotid artery stenting (CAS) with carotid endarterectomy (CEA). The study is published in European Journal of Vascular and Endovascular Surgery (EJVES; 2019;58:479–493).
The investigators conducted a systematic review and meta-analysis of data from the 20 RCTs in 126 publications and found that CAS confers higher rates of 30-day death/stroke than CEA; however, after 30 days, ipsilateral stroke is virtually identical for CEA and CAS.
As summarized in EJVES, the 30-day death/stroke rate was significantly higher after CAS versus CEA in seven RCTs composed of 3,467 asymptomatic patients (odds ratio [OR], 1.64; 95% confidence interval [CI], 1.02–2.64) and in 10 RCTs involving 5,797 symptomatic patients (OR, 1.71; 95% CI, 1.38–2.11).
Additionally, the investigators found:
- Excluding procedural risks, late ipsilateral stroke was approximately 4% at 9 years for both CEA and CAS (ie, CAS was durable)
- Reducing procedural death/stroke after CAS may be achieved through better case selection; for example, performing CEA in symptomatic patients aged > 70 years, interventions within 14 days of symptom onset, and situations where stroke risk after CAS is predicted to be higher (segmental/remote plaques; plaque length > 13 mm; heavy burden of white matter lesions [WMLs], where two or more stents might be needed).
- New WMLs were significantly more common after CAS (52% vs 17%) and were associated with higher rates of late stroke/transient ischemic attack (23% vs 9%), but there was no evidence that new WMLs predisposed toward late cognitive impairment
- Restenoses were more common after CAS (10%) but did not increase late ipsilateral stroke
- Restenoses (70%–99%) after CEA were associated with a small but significant increase in late ipsilateral stroke (OR 3.87, 95% CI 1.96–7.67; P < .001).
According to the investigators in EJVES, key questions still to be resolved include the following:
1. Will newer stent technologies and improved cerebral protection allow CAS to be performed < 14 days after symptom onset with risks similar to CEA?
2. What is the optimal volume of CAS procedures to maintain competency?
3. How to deliver better risk factor control and best medical treatment?
4. Is there a role for CEA/CAS in preventing/reversing cognitive impairment?