Carotid Endarterectomy For Symptomatic Stenosis Research Articles

Relationship between CT-derived cervical muscle mass and quality, systemic inflammation, and survival in symptomatic patients undergoing carotid endarterectomy.

Sarcopenia appears to be associated with inferior outcomes in surgical conditions. Chronic systemic inflammation confers an inferior long-term prognosis in cardiovascular disease and is associated with the development of sarcopenia. The aim of this study was to describe the prognostic role of sarcopenia assessed using computed tomography (CT)-derived body composition analysis and systemic inflammation in patients undergoing carotid endarterectomy for symptomatic carotid stenosis. In this retrospective cohort study, patients undergoing carotid endarterectomy for symptomatic carotid stenosis between 1 January 2011 and 1 October 2021 at four referral centres were included. The C3 skeletal muscle index and C3 skeletal muscle density were recorded from preoperative CT images. Systemic inflammation was assessed using the preoperative systemic inflammatory grade (SIG). The primary outcome was overall mortality during the study interval. A total of 618 patients were included, with a median follow-up of 69 (interquartile range 34-85) months. On univariable analysis, age greater than or equal to 75 years (P < 0.001), American Society of Anesthesiologists (ASA) grade greater than II (P < 0.001), low C3 skeletal muscle index (P = 0.002), low C3 skeletal muscle density (P < 0.001), SIG greater than or equal to 2 (P < 0.001), and low L3 derived skeletal muscle index (P < 0.001) were associated with increased mortality, whereas body mass index greater than or equal to 25 kg/m2 was associated with decreased mortality (P = 0.023). On multivariable analysis, age 75 years or older (HR 2.17 (95% c.i. 1.58 to 2.97), P < 0.001), ASA grade greater than II (HR 2.06 (95% c.i. 1.35 to 3.12), P < 0.001), low C3 skeletal muscle density (HR 1.84 (95% c.i. 1.33 to 2.54), P < 0.001), and SIG greater than or equal to 2 (HR 1.63 (95% c.i. 1.33 to 1.99), P < 0.001) were independently associated with increased mortality. Cervical CT-derived muscle mass and density, and markers of systemic inflammation, such as systemic inflammatory grade, may be associated with an inferior long-term prognosis after carotid endarterectomy.

Stroke After Endarterectomy for Symptomatic Carotid Stenosis: The Role of Intervention Timing and Preoperative Symptoms

Stroke After Endarterectomy for Symptomatic Carotid Stenosis: The Role of Intervention Timing and Preoperative Symptoms

Delaying Carotid Endarterectomy 3-4 Days From Admission Date Allows Lower Stroke Risk in Patients Who Had Carotid Endarterectomy for Symptomatic Carotid Stenosis With Moderate-to-Severe Disability

Delaying Carotid Endarterectomy 3-4 Days From Admission Date Allows Lower Stroke Risk in Patients Who Had Carotid Endarterectomy for Symptomatic Carotid Stenosis With Moderate-to-Severe Disability

Effect of the Pre-Operative Systemic Inflammatory Response on Outcomes Following Carotid Endarterectomy for Symptomatic Carotid Stenosis

Objective: Stroke accounts for over 100 000 acute hospital presentations per year in the UK, and approximately 4 500 carotid endarterectomies are performed annually in the UK.1 This is despite a relative paucity of cases performed for asymptomatic carotid stenosis, in comparison with other countries.1 Periprocedural stroke and death rates have fallen in recent years,2 although these remain notable risks necessitating careful patient selection and counselling. Chronic activation of the systemic inflammatory response (SIR) is prevalent in patients with atherosclerotic disease and influences both the pathogenesis and prognosis.3,4 The neutrophil:lymphocyte and platelet:lymphocyte ratios (NLR, PLR) are markers of the SIR, and are reported to provide prognostic value in patients with acute stroke,5 and in patients undergoing carotid endarterectomy.6 The Modified Glasgow Prognostic Score (mGPS) is calculated from C-reactive protein (CRP) and albumin and was originally described in patients with cancer.7 More recently mGPS has been shown to provide prognostic value in non-cancer patient groups.8 mGPS is representative of an alternative pathway activating the SIR and is not reported in relation to carotid endarterectomy outcomes. The present study describes experience of the prognostic value of these pre-operative markers of SIR in patients undergoing carotid endarterectomy.

Abstract Number ‐ 168: Conventional angiography versus non‐invasive imaging in the assessment of symptomatic carotid disease

Introduction The indication for carotid endarterectomy in symptomatic carotid stenosis of 50% or more was established based on catheter angiography. Yet, in practice, operative referral is still largely based on non‐invasive imaging. We sought to determine the discrepancy between the two modalities in our retrospective cohort. Methods We retrospectively collected data from consecutive symptomatic patients between 2019 and 2021 at our institution who were referred for evaluation and possible stenting of carotid disease based on non‐invasive imaging showing moderate to severe stenosis or occlusion. All patients underwent digitally subtracted angiography (DSA) and were treated with stenting if there was stenosis of 50% or above or if there was presence of a string sign. Otherwise, they were continued on best medical therapy. Results 98 total patients were referred for evaluation of carotid disease (Median age 60, 37% women). 21/98 were found to have a carotid occlusion on non‐invasive imaging, of those, 6 (28%) were found to have a string sign on CTA and were treated with stenting. 77/98 were found to have moderate to severe carotid artery stenosis based on non‐invasive imaging. Of those, 31 patients (40%), were not found to have significant carotid artery stenosis and were not treated with stenting. Out of total 99 patients who were referred for carotid intervention based on non‐invasive imaging, 38 (40%) patients had a change in the treatment plan. Conclusions 40% of the patients who were referred for revascularization based on non‐invasive imaging had a change in the treatment after conventional catheter angiography. Larger studies are warranted to confirm our findings.

Carotid Endarterectomy for Symptomatic Carotid Stenosis: Differences in Patient Profile in a Low-Middle-Income Country

Introduction: Carotid endarterectomy (CEA) is the standard treatment for patients with symptomatic carotid stenosis. Data from low- and middle-income countries are sparse on CEA and its outcomes. We aimed to describe the profile of our patients and factors associated with periprocedural cerebral ischemic events in patients with symptomatic carotid stenosis who underwent CEA in our institute. Methods: Retrospective review of patients with symptomatic carotid stenosis (50–99%) who underwent CEA between January 2011 and December 2021 was done. Clinical and imaging parameters and their influence on periprocedural cerebral ischemic events were analyzed. Results: Of the 319 patients (77% males) with a mean age of 64 years (SD±8.6), 207 (65%) presented only after a stroke. Majority (85%) had high-grade stenosis (≥70%) of the symptomatic carotid. The mean time to CEA was 50 days (SD±36); however, only 26 patients (8.2%) underwent surgery within 2 weeks. Minor strokes and TIA occurred in 2.2%, while major strokes and death occurred in 4.1% patients. None of the clinical or imaging parameters predicted the periprocedural cerebral ischemic events. The presence of co-existing significant (≥50%) tandem intracranial atherosclerosis (n = 77, 24%) or contralateral occlusion (n = 24, 7.5%) did not influence the periprocedural stroke risk. Conclusion: There is a delay in patients undergoing CEA for symptomatic carotid stenosis. Majority have high-grade stenosis and present late only after a stroke reflecting a lack of awareness. CEA can be performed safely even in patients with significant intracranial tandem stenosis and contralateral carotid occlusion.

Treatment of asymptomatic carotid artery stenosis

There is much debate about the best approach for treating patients with tight (at least 70%) asymptomatic carotid artery stenosis. A pooled analysis of trials in recently symptomatic patients with carotid artery stenosis showed that successful, uncomplicated surgery or stenting had similar long-term outcomes for at least 8 years, but early post-procedural strokes were more common after stenting than surgery. 1 Brott TG Calvet D Howard G et al. Long-term outcomes of stenting and endarterectomy for symptomatic carotid stenosis: a preplanned pooled analysis of individual patient data. Lancet Neurol. 2019; 18: 348-356 Summary Full Text Full Text PDF PubMed Scopus (57) Google Scholar The ACST-2 trial reported that, for asymptomatic patients, both procedures had similar procedural and 5-year follow-up outcomes. 2 Halliday A Bulbulia R Bonati LH et al. Second asymptomatic carotid surgery trial (ACST-2): a randomised comparison of carotid artery stenting versus carotid endarterectomy. Lancet. 2021; 398: 1065-1073 Summary Full Text Full Text PDF PubMed Scopus (47) Google Scholar However, medical treatment for asymptomatic carotid artery stenosis has improved substantially in the past 20 years, when many clinical trials in this population were done, and best medical treatment could now be an option instead of more invasive approaches. Carotid endarterectomy or stenting or best medical treatment alone for moderate-to-severe asymptomatic carotid artery stenosis: 5-year results of a multicentre, randomised controlled trialCEA plus BMT or CAS plus BMT were not found to be superior to BMT alone regarding risk of any stroke or death within 30 days or ipsilateral stroke during the 5-year observation period. Because of the small sample size, results should be interpreted with caution. Full-Text PDF

Early Carotid Endarterectomy for Symptomatic Internal Carotid Artery Stenosis in the Acute Ischemic Stroke

Objective: To research the results of the microsurgical treatment of symptomatic internal carotid artery stenosis by Carotid Endarterectomy in the acute period of a stroke that were performed in the Neurosurgery Department of IMSP IMU. Materials and Methods: A retrospective data collection was conducted on all consecutive patients surgically treated for an extra-cranial internal carotid artery (ICA) hemodynamic stenosis in the Neurosurgery Department of the Emergency Medicine Institute,in Chisinau (Rebublic of Moldova),between February 2019 and March 2021.All patients undergoing ICA endarterectomy for symptomatic carotid stenosis (SCS) within 48 hours and 14 days after the acute neurologic onset were included in the present study.Outcomes were evaluated by a prospective follow-up. Primary outcomes were the rate of postoperative ipsilateral stroke, myocardial infarction (MI), peripheral nerve injury, hematoma in the operating area and death.Secondary outcomes were the rate of local and systemic complications.The results were stratified according NIHSS score and comorbidities 30 days after surgery,and a multivariate analysis were performed in order to define any correlation between preoperative data and postoperative outcomes. Results: A total of 40 patients (10 %, n 4 bilateral and 90%, n 36 unilateral) underwent carotid endarterectomy (CEA) for hemodynamically significant ICA stenosis. According to inclusion criteria (22% women vs 78% men; median age 64 years, range: 54-76; median preoperative NIHSS score 4, range 0-18) all patients affected by SCS were enrolled in the present study. Median delay for surgery was 6 days (range: 2-14).During in-hospital post-operative period the combined death/stroke/MI rate was 0%.In-hospital NIHSS score improved post-operatively of more than 2 points (range 0-12) in 45.7% of cases.Microsurgical CEA is accompanied,in most cases by the regression of neurological symptoms and it is not correlated with the increased risk for a hemorrhagic transformation.No local and systemic complications were registered.The stratification of outcomes according to NIHSS status, sex, comorbidities did not show any statistical relation neither at 30 days nor at the long term-follow up. Conclusion: In properly selected patients with a SCS, affected by an acute ischemic stroke, early carotid endarterectomy can be performed without any complications or worsening of neurological status in comparison with similar cases in a longer period after a stroke.

Impact of Shunting Practice Patterns During Carotid Endarterectomy for Symptomatic Carotid Stenosis.

We aimed to assess the effect of surgeons' shunting practice and shunt use on the early outcomes of carotid endarterectomy (CEA) in recently symptomatic patients. We conducted a retrospective observational study based on a multicenter national prospective database. The Vascular Quality Initiative database (2010-2019) was queried for CEAs performed within 14 days after an ipsilateral stroke or transient ischemic attack. Surgeons were gauged as routine shunters if they shunted in >95% of CEAs, otherwise were classified as selective shunters. In-hospital stroke and death rates were compared between routine and selective shunters, stratifying by type of index event (transient ischemic attack versus stroke) and timing of CEA (≤2 versus >2 days). Thirteen thousand four hundred sixty-nine CEAs were performed after a transient ischemic attack (43%) or stroke (57%), 3186 (24%) by routine shunters, and 10 283 (76%) by selective shunters. Comparing routine and selective shunters, in-hospital stroke (1.9% versus 2.4%; P=0.09) and death (0.4% versus 0.5%; P=0.73) rates were similar. A lower stroke rate (1.5% versus 4.2%; P=0.02) was achieved by routine shunters for CEA performed <2 days after an ischemic stroke. Among selective shunters, a higher stroke rate occurred in case of shunt use (2.9% versus 2.3%; P<0.01), mainly due to cases presenting with stroke (3.5% versus 2.4%; P<0.01) but not transient ischemic attack (1.8% versus 1.5%; P=0.57). Awake anesthesia was adopted in 7.8% of cases by selective shunters and in 0.8% by routine shunters, without impact on the perioperative stroke rate (1.8% versus 2.3%; P=0.349). In this large national cohort, the overall outcomes of CEA were similar between routine and selective shunters. A lower postoperative stroke rate was achieved by routine shunters in CEA performed <2 days after an ischemic stroke. Among selective shunters, intraoperatively indicated shunting determined an increased stroke rate, likely due to intraoperative hypoperfusion. These data may guide the decision regarding timing of CEA and shunting intention in symptomatic patients.

The Weekend Effect in Carotid Endarterectomy for Symptomatic Carotid Stenosis.

BackgroundRecent studies report a limited window in which carotid endarterectomy (CEA) provides the greatest benefit for symptomatic carotid stenosis. Given the time-sensitive nature of CEA for symptomatic stenosis, it is important to understand whether patient outcomes are adversely affected by undergoing CEA over the weekend. Currently, it is unclear whether CEA is impacted by the "weekend effect" phenomenon. Methods A multi-institutional database was queried for all patients undergoing CEA for symptomatic carotid artery stenosis from 2015 to 2020 via ICD-9 codes. A total of 288 patients were identified during the study period. Univariate and multivariate analysis were used to compare outcomes based on weekend vs weekday surgery. Results A total of 261 patients (90.6%) underwent weekday CEA, as compared to 27 (9.4%) on the weekend. There were no differences in age, race, gender, or medical comorbidities between groups. Primary surgeon specialty was predominantly vascular surgery (77.0% weekday and 74.1% weekend) followed by neurosurgery (19.9% weekday and 25.9% weekend). Operative time was similar between groups (3.1 (weekday) vs 2.9 hr (weekend), P = .33) as well as estimated blood loss (100 vs 100mL, P = .54). Hospital length of stay did not differ between groups (P = .69). Combined stroke and 30-day mortality rate was 2.0% on weekdays, compared to 3.7% on weekends (P = .75). On multivariate analysis, weekend surgery was not predictive of postoperative stroke or 30-day mortality (odds ratio .11 [95% CI: -1.57 to 1.85], P = .90). Conclusion In our multi-institutional experience, we did not identify a "weekend effect" in patients undergoing CEA for symptomatic carotid artery stenosis. Surgical revascularization should not be withheld on account of a weekend procedure in similar academic medical centers.

Symptoms to surgery: factors associated with delays to carotid endarterectomy for symptomatic stenosis in an Irish tertiary vascular centre

Introduction: Carotid endarterectomy (CEA) is the accepted treatment for stroke risk reduction in patients with symptomatic 50–99% carotid artery stenosis. Best practice guidelines recommend surgery be performed within 14 days of index symptoms to achieve maximum benefit; however, achieving this target can be difficult. Late presentation and presentation to hospitals without onsite vascular capabilities are two recurring reasons for delayed CEA across the literature. Methods: All symptomatic CEAs performed between January 2017 and December 2019 were retrospectively extracted from an electronic institutional database and analysed to determine the proportion of CEAs meeting benchmark targets and to assess factors contributing to delays. Results: A total of 124 CEAs were performed for 62 strokes and 62 transient ischaemic attacks (TIAs); 71.8% (n=89) were male and the median (range) age was 71.0 years (43–88). The median delay between initial symptom and CEA was 14 days (range 1–183). Sixty-six patients (55%) had surgery within 14 days of the index symptom. Patients presenting with ‘Face Arms Speech Time’ (FAST) symptoms were significantly more likely to undergo timely CEA, largely due to earlier presentation to hospital (p=0.021, OR 2.563, 95% CI 1.143 to 5.747). Presentation directly to a tertiary vascular centre was significantly associated with CEA within 14 days compared with referrals from external hospitals (p=0.002), with a median symptom-to-surgery interval of 12.0 days and 25.0 days, respectively (p=0.001) Conclusions: Our results are comparable to UK and Australian national audits, although a significant number of CEAs fell outside the 14-day target. Protected pathways between referring hospitals and vascular centres are needed to ensure all patients have equal access to urgent CEA. Designating CEA within 14 days as a key performance indicator for stroke management will hopefully incentivise hospitals to expedite this high-risk cohort. Furthermore, re-auditing with an emphasis on patients turned down for intervention due to recurrent events while awaiting CEA may further highlight the need to prioritise symptomatic carotids.

Impact of Shunting Practice Patterns During Carotid Endarterectomy for Symptomatic Carotid Stenosis: Supra-Aortic Arterial Disease

Introduction: The impact of shunting practice patterns on the outcomes of carotid endarterectomy (CEA) in acutely symptomatic patients is unclear. The aim of the study was to assess the effect of surgeons’ shunting practice and shunt use on the early outcomes of CEA performed within 14 days from an index neurological event.

A Modern Series of Carotid Endarterectomy for Symptomatic Carotid Stenosis

Carotid endarterectomy (CEA) is the standard of care for symptomatic patients with moderate-to-severe carotid stenosis. We reviewed our recent multi-institutional experience with CEA to highlight techniques and outcomes in the modern era.

O37 Carotid surgery during the COVID-19 pandemic

Abstract Introduction The aim of this prospective study was to evaluate the efficacy and safety of carotid endarterectomy for symptomatic carotid stenosis during the COVID-19 pandemic. Method Re-organisation of stroke services due to the COVID-19 pandemic resulted in carotid endarterectomy for symptomatic disease being performed in two hospitals; Covid-19 free and non-free sites. Patients were referred from multiple online regional neurovascular multi-disciplinary team meetings, and managed according to the pre-Covid-19 guidance. All patients referred for carotid endarterectomy between 23 March 2020 and 31 July 2020 were included. Demographic, medical history, imaging, peri-operative, complication and follow-up data were collected and analysed prospectively. Result 28 patients were referred for carotid endarterectomy, of whom 21 patients underwent surgery. The mean time to surgery was 11 days (3–35). The technical success rate was 100%. Peri-operatively and within 30-days post-operatively, no patient suffered death or stroke. There were 2 minor complications; one non-ST elevation myocardial infarction, and another wound haematoma and infection requiring readmission for antibiotics. No patient developed new COVID-19 infection post-operatively. Of the 7 patients not operated on; 2 were medically unfit for surgery, three declined surgery, and two had free floating thrombus that was managed successfully with anti-coagulation. Conclusion During the pandemic, the provision of carotid endarterectomy for symptomatic carotid diseases was carried out safely and within the current recommendations, with several pre-cautionary measures being undertaken. Therefore, symptomatic carotid intervention should still be considered to reduce the risk of stroke provided similar pre-cautionary measures are undertaken. Take-home Message Carotid surgery should continue during successive waves of the COVID-19 pandemic

Early carotid endarterectomy for symptomatic stenosis of internal carotid artery in the acute ischemic stroke

Early carotid endarterectomy for symptomatic stenosis of internal carotid artery in the acute ischemic stroke

Carotid endarterectomy in acute period of ischemic stroke

A review is devoted to carotid endarterectomy for symptomatic carotid stenosis in acute period of ischemic stroke. Patient selection criteria, dates of surgical intervention and perioperative risk were analyzed.

Prevalence and the Risk Factors for Asymptomatic Carotid Artery Stenosis Among Type II Diabetes Mellitus Patients

Prevalence and the Risk Factors for Asymptomatic Carotid Artery Stenosis Among Type II Diabetes Mellitus Patients

Associations of Perioperative Variables With the 30-Day Risk of Stroke or Death in Carotid Endarterectomy for Symptomatic Carotid Stenosis.

Background and Purpose- This analysis was performed to assess the association between perioperative and clinical variables and the 30-day risk of stroke or death after carotid endarterectomy for symptomatic carotid stenosis. Methods- Individual patient-level data from the 5 largest randomized controlled carotid trials were pooled in the Carotid Stenosis Trialists' Collaboration database. A total of 4181 patients who received carotid endarterectomy for symptomatic stenosis per protocol were included. Determinants of outcome included carotid endarterectomy technique, type of anesthesia, intraoperative neurophysiological monitoring, shunting, antiplatelet medication, and clinical variables. Stroke or death within 30 days after carotid endarterectomy was the primary outcome. Adjusted risk ratios (aRRs) were estimated in multilevel multivariable analyses using a Poisson regression model. Results- Mean age was 69.5±9.2 years (70.7% men). The 30-day stroke or death rate was 4.3%. In the multivariable regression analysis, local anesthesia was associated with a lower primary outcome rate (versus general anesthesia; aRR, 0.70 [95% CI, 0.50-0.99]). Shunting (aRR, 1.43 [95% CI, 1.05-1.95]), a contralateral high-grade carotid stenosis or occlusion (aRR, 1.58 [95% CI, 1.02-2.47]), and a more severe neurological deficit (mRS, 3-5 versus 0-2: aRR, 2.51 [95% CI, 1.30-4.83]) were associated with higher primary outcome rates. None of the other characteristics were significantly associated with the perioperative stroke or death risk. Conclusions- The current results indicate lower perioperative stroke or death rates in patients operated upon under local anesthesia, whereas a more severe neurological deficit and a contralateral high-grade carotid stenosis or occlusion were identified as potential risk factors. Despite a possible selection bias and patients not having been randomized, these findings might be useful to guide surgeons and anesthetists when treating patients with symptomatic carotid disease.

Early Carotid Endarterectomy for Symptomatic Stenosis of Internal Carotid Artery in Patients Affected by Transient Ischemic Attack or Minor-to-Moderate Ischemic Acute Stroke: A Single-Center Experience

In the setting of carotid transient ischemic attack (TIA) or minor/moderate ischemic stroke, early surgical endarterectomy (CEA) seems to decrease the number of recurrences. The aim of the present study was to report a single-center experience with early surgical carotid revascularization in patients affected by TIA and minor/moderate ischemic acute stroke. A retrospective data collection was carried out on all consecutive patients surgically treated for an extracranial internal carotid artery (ICA) hemodynamic NASCET stenosis in the Vascular Unit of Foch Hospital, in Suresnes (France) between January 2011 and July 2016. All patients undergoing ICA endarterectomy for symptomatic carotid stenosis (SCS) within 48 hours and 14 days after the acute neurologic onset were included in the present study. Outcomes were evaluated by a prospective follow-up. Primary outcomes were the rate of postoperative ipsilateral stroke and myocardial infarction (MI) and the death/stroke/MI at 30-day and at the long-term follow-up. Secondary outcomes were local and systemic complications' rate. Outcomes were stratified according to NIHSS score and comorbidities, and a univariate analysis and multivariate analysis were performed to define any correlation between preoperative data and postoperative outcomes. A total of 249 consecutive patients (45.4%, 113 symptomatic vs. 54.6%, 136 asymptomatic) underwent CEA for hemodynamically significant ICA stenosis at our institution. According to inclusion criteria, 72 patients affected by SCS (27.7% women vs. 72.3% men; median age 71.9 years, range: 42-89; median preoperative NIHSS score 3, range 1-17) were enrolled in the present study. Median delay for surgery was 4 days (range: 2-14). No in-hospital stroke, nor myocardial infarction nor death were detected during in-hospital post-operative period. The combined death/stroke/MI rate was 0% and 5.5 % at 30-days at 6 years follow-up respectively. In-hospital NIHSS score improved post-operatively of more than 2 points (range 0-15) in 47.2% of cases. A total of 10 patients (13.8%) experienced a local complication (hematoma, permanent or regressive nerve injury). No systemic complications (renal/respiratory failure, urinary tract infection, pneumoniae) were registered. At long-term follow-up a total of four patients (5.5%) died and six patients (8.3%) were lost. The stratification of outcomes according to NIHSS status, sex, comorbidities and preoperative surgical procedure did not show any statistical relation neither at 30 days nor at the long term-follow up. Diabetes was statistically correlated to a higher rate of complication at the long-term follow-up (P 0.049). In properly selected patients affected by minor/moderate ischemic acute stroke and TIA early carotid endarterectomy can be performed without any worsening of neurological status.

Secular Trends in Procedural Stroke or Death Risks of Stenting Versus Endarterectomy for Symptomatic Carotid Stenosis.

Over the past decades, stroke risk associated with carotid disease has decreased, reflecting improvements in medical therapy and a more rigorous control of vascular risk factors. It is less clear whether the procedural risk of carotid revascularization has declined over time. We analyzed temporal changes in procedural risks among 4597 patients with symptomatic carotid stenosis treated with carotid artery stenting (n=2326) or carotid endarterectomy (n=2271) in 4 randomized trials between 2000 and 2008, using generalized linear mixed-effects models with a random intercept for each source trial. Models were additionally adjusted for age and other baseline characteristics predicting treatment risk. The primary outcome event was any procedural stroke or death, occurring during or within 30 days after revascularization. The procedural stroke or death risk decreased significantly over time in all patients (unadjusted odds ratio per year, 0.91; 95% CI, 0.85-0.97; P=0.006). This effect was driven by a decrease in the carotid endarterectomy group (unadjusted odds ratio per year, 0.82; 95% CI, 0.73-0.92; P=0.003), whereas no significant decrease was found after carotid artery stenting (unadjusted odds ratio, 0.96; 95% CI, 0.88-1.04; P=0.33). Carotid endarterectomy patients had a lower procedural stroke or death risk compared with carotid artery stenting patients, and the difference significantly increased over time (interaction P=0.031). After adjustment for baseline characteristics, the results remained essentially the same. The risk of stroke or death associated with carotid endarterectomy for symptomatic carotid stenosis decreased over an 8-year period, independent of clinical predictors of procedural risk. No corresponding reduction in procedural risk was seen in patients treated with stenting. URL: https://www.clinicaltrials.gov; http://www.isrctn.com. Unique identifier: NCT00190398 (EVA-3S), NCT00004732 (CREST), ISRCTN57874028 (SPACE), and ISRCTN25337470 (ICSS).