Stroke/Death Rates Following Carotid Artery Stenting and Carotid Endarterectomy in Contemporary Administrative Dataset Registries: A Systematic Review.

Abstract

Introduction: Randomized trials have reported contradictory findings regarding outcomes after carotid artery stenting (CAS) versus carotid endarterectomy (CEA). Despite this, the 2011 American Heart Association (AHA) guidelines expanded CAS indications, partly because of data from the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST), but also because of improving outcomes in Industry-sponsored ‘high risk for CEA’ CAS Registries. The aim of the current systematic review was to see whether there was a parallel reduction in procedural risk after CAS in contemporary administrative dataset registries. Methods: PubMed/Medline, Embase and Cochrane databases were systematically searched from January 1, 2008 until February 23, 2015 for administrative dataset registries reporting outcomes after both CEA and CAS. Results: Twenty-one registries reported outcomes after >1,500,000 procedures. CAS had similar stroke/death rates with CEA in one registry involving ‘average risk’ asymptomatic and in two registries involving ‘average risk’ symptomatic patients. Stroke/death rates after CAS were significantly higher than CEA in 9/15 registries involving ‘average risk’ asymptomatic and in 11/18 registries involving ‘average risk’ symptomatic patients. In five registries, CAS was associated with higher stroke/death rates than CEA for both symptomatic and asymptomatic patients, but formal statistical comparison was not reported. CAS was associated with stroke/death rates that exceeded risk thresholds recommended by the AHA in 9/15 registries involving ‘average risk’ asymptomatic patients and in 13/18 registries involving ‘average risk’ symptomatic patients. In 5/18 registries, the procedural risk after CAS in ‘average risk’ symptomatic patients exceeded 10%. Conclusion: Data from contemporary administrative dataset registries suggest that stroke/death rates following CAS remain significantly higher than after CEA and frequently exceed accepted AHA thresholds. In this systematic review, there was no evidence of a sustained decline in procedural risk after CAS. The extremely high published risks in some symptomatic registries suggest that clinical governance is not being applied.