Long term follow-up of carotid endartectomy vs stenting

The Lancet

Atherosclerotic stenosis of the internal carotid artery accounts for 10–15% of strokes. Prior trials comparing stenting with CEA for symptomatic carotid stenosis demonstrated that stenting was associated with a higher risk of stroke, but lower rates of myocardial infarction, access site hematoma, and cranial nerve palsy.  The majority of reported adverse events are periprocedural, but long-term outcomes remain unclear.  In the International Carotid Stenting Study, 1710 patients with symptomatic carotid artery stenosis randomized to stenting or CEA were followed for a median of 4.2 years (IQR 3.0-5.2, maximum 10).  The 5-year risk of fatal or disabling strokes did not differ between the stenting and CEA cohorts (6.4% vs 6.5%).  The incidence of any strokes was significantly higher in the stenting group (15.2% vs 9.4%) with a 5-year cumulative risk of 8.9% versus 5.8%.  This did not have a major impact on overall functional outcome; 1 and 5 year modified Rankin scale scores were not significantly different between cohorts.  As such it would appear that CEA still likely remains the best treatment in decreasing the incidence of strokes following intervention for symptomatic carotid artery stenosis.  Further ongoing trials may better delineate the best intervention for specific patient cohorts.

Robert M. Starke, MD MSC
Charlottesville, VA