Carotid Surgery Is the Gold Standard for High-Risk (HRP) Carotid Artery Intervention: Five-Year Cost-Effectiveness and Quality Stroke-Free Survival Comparison Between Carotid Endarterectomy (CEA), Carotid Angioplasty, and Stenting Technique (CAST), and Optimal Medical Therapy (OMT)

Abstract

Background: Our aim was to conciliate carotid angioplasty and stenting technique (CAST) with CEA and optimal medical therapy (OMT) in high-risk patients. Primary end points were stroke, myocardial infarction, or death. Secondary end points were patency rate, cost-effectiveness, length of hospital stay, reintervention rate, quality of life, Q-TwiST (Quality-Adjusted Time Without Symptoms of Disease or Toxicity of Treatment), and cost per quality-adjusted life-year (QALY). Methods: Between October 2001 and October 2008, 847 patients were evaluated with carotid stenosis >60%. Predicted probability of receiving CEA, CAST, and OMT was tabulated using multiple logistic regressions to control for comorbidity and anatomic high-risk factors. Propensity scoring adjusted for baseline characteristics and selection bias by matching covariables, creating a pseudorandomized control design for 306 CEA, 39 CAST, and 275 OMT, of which computer randomization generated 55 CEA, 34 CAS, and 67 OMT. Nineteen (6.3%) had bilateral interventions. Comorbidity Severity Scores were similar between groups (P > .05) Results: All interventions were within a mean of 18 days from initial presentation. Mean age was similar between CEA (68.6 years) and CAST (70.6 years, P > .05) but OMT patients were significantly older (75.4 years) than CEA (P < .01) or CAST patients (P < .05). Duplex ultrasound was the sole preoperative imaging modality to quantify plaque-type morphology and degree of stenosis. After carotid intervention, overall 30-day stroke free survival rate was 99.1% (95% CI, 99.6%-99.9%). The 5-year stroke-free rate was 99.1% (95% CI, 99.6%-99.9%), stroke-free survival was 90.6% (95% CI, 85.9%-93.9%), and primary patency was 94.6% (95% CI, 90.5%-97.0%). The 5-year stroke free survival significantly improved with CEA (90.6%) compared with OMT (44.3%, H = .22; 95% CI, .08-.61; P < .0001). Cox proportional hazards ratio showed age >80 years (P < .001), female gender (P < .04), and echolucent plaque material (P < .01) were associated with reduced stroke free survival. Q-TwiST, and cost per QALY were in favor of CEA vs CAST (P > .05) and significantly improved with CEA vs OMT (P < .0001) and CAST (P < .001). Conclusions: OMT does not prevent future stroke in patients with severe carotid artery disease. Indications for CAST are limited, and strict selection criteria should apply. Contemporary trends verify that stenting techniques and cerebral protection devices prerequisite device maturity before it befalls routine clinical practice. CEA is the gold standard in suitable patients with recently symptomatic carotid artery stenosis, with superior stroke-free survival rates at 5 years when compared with CAST or OMT.