Safety Of Carotid Artery Stenting Research Articles

Letter to Editor Regarding “Comparison of Perioperative Safety of Carotid Artery Stenting and Endarterectomy in the Treatment of Carotid Artery Stenosis: A Meta-Analysis of Randomized Controlled Trials”

Letter to Editor Regarding “Comparison of Perioperative Safety of Carotid Artery Stenting and Endarterectomy in the Treatment of Carotid Artery Stenosis: A Meta-Analysis of Randomized Controlled Trials”

Successful retrieval of a retained cerebral protection device using esophageal biopsy forceps

Abstract: Cerebral protection devices (CPDs) often were applied to improve the safety of carotid artery stenting, but the CPD itself may cause fatal complications. We report a case of a retained CPD that was an Emboshield NAV6 device left in situ, which was retrieved successfully with esophageal biopsy forceps.

Comparison of Perioperative Safety of Carotid Artery Stenting and Endarterectomy in the Treatment of Carotid Artery Stenosis: A Meta-Analysis of Randomized Controlled Trials

Current management guidelines for the treatment of carotid stenosis are controversial. We performed this meta-analysis to evaluate the perioperative safety of carotid artery stenting (CAS) and endarterectomy. We systematically searched EMBASE, PubMed, Web of Science, and the Cochrane Library from inception to November 10, 2022, for randomized controlled trials that compared CAS with carotid endarterectomy (CEA) among patients with carotid stenosis. The analyzed outcomes mainly included stroke, death, myocardial infarction (MI), cranial nerve palsy, the cumulative incidence of mortality, stroke, or MI and the cumulative incidence of death or stroke in the perioperative periods. The risk ratio (RR) and 95% confidence interval (95% CI) were calculated and pooled. Subgroup analyses were based on whether patients were symptomatic or asymptomatic. We assessed the certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation framework. Seventeen randomized controlled trials with 12,277 participants (6514 and 5763 in the CAS and CEA groups, respectively) were included. Pooled analysis demonstrated that compared with CEA, CAS was associated with decreased risks of perioperative MI (RR=0.47, 95% CI=0.29∼0.77) and perioperative cranial nerve palsy (RR=0.02, 95% CI=0.01∼0.06) but higher risks of perioperative stroke (RR=1.48, 95% CI=1.18∼1.87) and cumulative incidence of death or stroke (RR=1.52, 95% CI=1.20∼1.93). The perioperative safety was equivalent between CAS and CEA. However, CEA may be preferred when considering both procedural safety and long-term efficacy in preventing recurrent stroke.

Carotid artery stenting using a 7 French Optimo balloon guide catheter combined with a distal filter.

Carotid artery stenting (CAS) by proximal occlusion of the common carotid artery (CCA) using a balloon guide catheter (BGC) is a simple proximal protection method to prevent distal embolism, however, it requires at least an 8 French (F) system. A 7 F Optimo BGC is the smallest BGC with an inner lumen diameter of 0.071 inches, and which permits the passage of a 5 F carotid stent. We retrospectively investigated the clinical results and the safety of CAS by using a 7 F Optimo BGC combined with a distal filter. One-hundred carotid arterial stenosis patients were treated with CAS using combined protection of a 7 F Optimo BGC and a distal filter. The BGC was navigated from the femoral and radial arteries in 85 and 15 patients, respectively. The 7 F Optimo BGC was successfully navigated into the CCA in all patients, and the technical success rate of CAS was 100%. Major adverse events of any death, stroke, or myocardial infarction within 30-day after the procedure were observed in one (1%). Post-procedural diffusion-weighted magnetic resonance imaging revealed high signals in 21% of the patients, all of whom were asymptomatic. The 7 F Optimo is the smallest BGC to achieve CAS using a proximal protection system. The combined use of a 7 F Optimo BGC and a distal filter is effective for navigating the BGC and distal embolic protection.

Carotid Artery Stenting for Asymptomatic Carotid Stenosis: What We Need to Know for Treatment Decision.

A clinical decision on the treatment of asymptomatic carotid stenosis is challenging, unlike symptomatic carotid stenosis. Carotid artery stenting (CAS) has been recommended as an alternative to carotid endarterectomy (CEA) based on the finding that the efficacy and safety of CAS were comparable to CEA in randomized trials. However, in some countries, CAS is often performed more frequently than CEA for asymptomatic carotid stenosis. Moreover, it has been recently reported that CAS is not superior to the best medical treatment in asymptomatic carotid stenosis. Due to these recent changes, the role of CAS in asymptomatic carotid stenosis should be revisited. When determining the treatment for asymptomatic carotid stenosis, one should consider several clinical factors including stenosis degree, patient life expectancy, stroke risk by medical treatment, availability of a vascular surgeon, high risk for CEA or CAS, and insurance coverage. This review aimed to present and pragmatically organize the information that is necessary for a clinical decision on CAS in asymptomatic carotid stenosis. In conclusion, although the traditional benefit of CAS is being revisited recently, it seems too early to conclude that CAS is no longer beneficial under intense and systemic medical treatment. Instead, a treatment strategy with CAS should evolve to select eligible or medically high-risk patients more precisely.

Predictive Factors for Stroke and TIA Following Carotid Artery Stenting.

Carotid artery stenting (CAS) is an effective and minimally invasive method for the treatment of extracranial carotid artery stenosis. The aim of the present study was to explore independent risk factors to predict cerebrovascular events following CAS to identify high-risk patients and improve the safety of CAS in this population. HISPANIAS is a national prospective multicenter study that included 14 hospitals that collected data from patients who underwent CAS. We analyzed morbidity and mortality within 30 days after CAS, looking for factors that might be associated with cerebrovascular events (stroke and transient ischemic attack [TIA]). The HISPANIAS cohort included 757 patients: 80.32% were men, the mean age was 70.73 years, and 82.96% underwent symptomatic CAS. Cerebrovascular complications occurred in 42 patients (5.6%), including TIA in 24 patients (70.8% ipsilateral; mean 2.79 days after CAS) and stroke in 18 patients (72.2% ipsilateral; mean 6.72 days after CAS). The main independent clinical predictors of stroke/TIA identified by logistic regression were female sex (odds ratio [OR] 2.29, 95% CI 1.15-4.54) and diabetes (OR 3.29, 95% CI 1.71-6.40). Survival analysis showed that diabetic women, compared with the rest of the patients, had a higher number of events concentrated mainly in the first days after the intervention (p=0.003). Cerebrovascular ischemic complications after CAS continue to be a challenge for the management of these patients. Although there are other factors, female sex and the presence of diabetes are emerging as strong risk factors for the development of complications after symptomatic CAS. Carotid artery stenting (CAS) is an effective and minimally invasive method for the treatment of extracranial carotid artery stenosis. Although CAS has been regarded as a reliable and safety approach, some studies reported that CAS was associated with a higher risk of procedure-related stroke. Cerebrovascular complications after CAS continue to be a main problem and a challenge for the management of these patients. Therefore, it is essential to identify the factors involved in the development of these complications. Our study shows that the combination of female sex and diabetes is associated with a clearly worse outcome, with a greater number of events concentrated mainly in the first days. This is different from other studies that have explored each factor separately. It would be interesting to perform separate interventions for this group given the increased risk of complications.

Impact of residual stenosis on clinical outcomes when performing carotid artery stenting without postdilation.

Many centers consider postdilation if the final angiography after carotid artery stenting (CAS) shows residual stenosis of >30% to 40%. Postdilation has been demonstrated to potentially increase the risk of developing neurologic events. This study aimed to investigate the safety of CAS without postdilation regardless of the degree of residual stenosis. We retrospectively investigated 191 patients who underwent transfemoral CAS without postdilation intendedly. All cases underwent mild predilation and self-expanding stent implantation. We divided the patients into a residual stenosis of ≥40% group (n= 69 [36.1%]) and a residual stenosis of<40% group (n= 122 [63.9%]) according to their final angiography. We compared the procedural (within 30days after CAS) and nonprocedural (afterward) adverse cardiovascular events and in-stent restenosis between the two groups. We also investigated the incidence of perioperative hemodynamic depression between the groups and the changes in residual stenosis over the follow-up time. Patients in the residual stenosis of ≥40% group had a higher preoperative stenosis rate and a greater proportion of severely calcified lesions than those in the<40% group. There was one procedural cardiac death (0.5%), five strokes (2.6%), and four myocardial infarctions (2.1%). A total of 2.9% had stroke or death procedurally in the residual stenosis of ≥40% group and 3.2% in the residual stenosis of<40% group (P> .950). The median nonprocedural follow-up time was 22months, with a total of six deaths and four strokes. The cumulative 2-year death or stroke rate was 6.2%, with 5.9% in the residual stenosis of ≥40% group versus 6.7% in the residual stenosis of<40% group (P= .507). There were two cases of in-stent restenosis in the residual stenosis of ≥40% group and three in the residual stenosis of<40% group (P= .927). The difference in the peak systolic velocity of the target lesion between groups at 3months after CAS was no longer present, and residual stenosis stabilized at 10% to 20% at 6months in both groups. The patients showed an association between increasing hemodynamic depression incidence and residual stenosis in a significantly graded response (P=.021). Residual stenosis after carotid stenting without postdilation is not associated with a risk of postoperative adverse events. This study provides evidence for the feasibility of a no postdilation strategy for CAS.

Radial and ulnar approach for carotid artery stenting with Roadsaver™ double layer micromesh stent:Early and long-term follow-up.

We aimed to evaluate the feasibility and safety of carotid artery stenting (CAS) with a newly designed double-layer micromesh stent using wrist approach in patients with significant carotid disease. Between January 2016 and December 2021, 105 patients undergoing CASwith Roadsaver™ stent were enrolled in a single center prospective study. Follow-up assessments included neurological exams, duplex ultrasound (DUS), and 12-lead ECG. The primary endpoint was the 30-day composite rate of stroke, death, and myocardial infarction. Secondary endpoints included procedure success, access site complications, device success, target lesion revascularization, and in-stent restenosis evaluated with DUS. Long-term outcomes up to 72 months of follow-up were assessed in all eligible patients. The study population was predominantly male (69.5%) with a median age of 68 ± 8 years. Patients were symptomatic in 80% of the cases, and 35% fulfilled the high-risk criteria for surgical endarterectomy. The right internal carotid artery was the target artery in 56 (53.4%), and the left in 49 (46.6%) of the cases. All procedures were successfully completed from the right wrist, with right radial access in 94 (89.5%) cases and ulnar artery access with previous radial artery occlusion in 11 (10.5%) cases. All patients were treated successfully with the study device. The primary endpoint was met with a 30-day major adverse eventrate of 0.9% (1/105). Up to 72 months of follow-up (median 30 ± 20 months) there were no strokes, neurological deaths, or target lesion revascularization of the treated lesion. Doppler ultrasound examination revealed nonsignificant in-stent restenosis in two asymptomatic patients. There was no hand ischemia detected in any patient. Results from this study demonstrate the radial and ulnar access for CASwith double layer micromesh Roadsaver™ stent is safe and feasible and associated with favorable early and long-term follow-up.

Age and Five-Year Outcomes After Carotid Artery Stenting in Symptomatic Carotid Stenosis: A Retrospective Cohort Study.

Several clinical trials have reported that periprocedural risk of carotid artery stenting (CAS) increase with age. China is experiencing one of the most rapid transitions to an aging society, while the clinical outcomes of CAS in real-world China are still limited. The study aimed to compare the periprocedural and an extending 5-year event rates between younger and older patients treated by CAS to testify the safety of CAS in older patients in China. This is a single center, retrospective cohort study. Symptomatic patients who underwent CAS from Nov 2011 to June 2014 were retrospectively included in this study, The population was divided into two age groups: <70 and ≥70. The main primary endpoint was stroke, myocardial infarction or death occurring at 30 days, or ipsilateral stroke over 5-year after stenting. A total of 103 symptomatic patients (<70: 68%; ≥70: 32%) with CAS included in the study. During the 30-day period, the rate of primary outcome was 1.0% with only one stroke in patients younger than 70years old (P = 1.000). After five years, the rate of primary outcome was low (10.9%, 10/92) despite some of the patients had major stroke or underwent bilateral C1 stenting. There was no significant difference in the 5-year rates of the primary outcome between the young and old groups (12.3% vs 7.4%, P = .718). Kaplan-Meier estimates of the proportion of study participants with a primary endpoint showed that there was no significant age-dependent difference of the stroke and death outcome in symptomatic patients. Age (<70 vs ≥ 70) had no influence on the risk of stroke or death in symptomatic patients either in the short or long term. CAS is an optimal treatment for older patients with cervical carotid artery stenosis, and CAS was safe for those with major stroke or bilateral C1 stenting.

Safety of Carotid Artery Stenting in Elderly Patients by Treatment Selection Based on Plaque Characteristics

Safety of Carotid Artery Stenting in Elderly Patients by Treatment Selection Based on Plaque Characteristics

Protected carotid artery stenting in patients with severe stenosis.

Intraplaque hemorrhage (IPH) and ulcers are the major findings of unstable plaques. In addition, initial symptoms are associated with postprocedural complications after carotid artery stenting (CAS). The aim of this study was to determine the safety of CAS using an embolic protection device in symptomatic patients with severe carotid artery stenosis and unstable plaques such as IPH and ulcers.This retrospective study included 140 consecutive patients with severe carotid stenosis. These patients underwent preprocedural carotid vessel wall imaging to evaluate the plaque status. We analyzed the incidence of initial clinical symptoms, such as headache, nausea, and vomiting, after CAS. The primary outcomes analyzed were the incidence of stroke, myocardial infarction, and death within 30 days of CAS.Sixty-seven patients (47.9%) had IPH, and 53 (38.9%) had ulcers on carotid wall imaging/angiography. Sixty-three patients (45.0%) had acute neurological symptoms with positive diffusion-weighted image findings. Intraluminal thrombi on initial angiography and flow arrest during CAS were significantly higher in patients with IPH and symptomatic patients. Symptoms were significantly higher in patients with IPH than in those without (63.5% vs 35.1%, P < .001). There were no significant differences in clinical symptoms after stenting or in primary outcomes, regardless of IPH, ulcer, or initial symptoms.IPH and plaque ulceration are risk factors in symptomatic carotid stenosis. However, IPH and plaque ulceration were not a significant risk factors for cerebral embolism during protected carotid artery stent placement in patients with carotid stenosis. Protected CAS might be feasible and safe despite the presence of unstable plaques.

Safety of the transradial approach to carotid stenting.

The multicenter prospective CREST-2 Registry (C2R) provides recent experience in performing carotid artery stenting (CAS) for interventionists to ensure safe performance of CAS. To determine the periprocedural safety of CAS performed using a transradial approach relative to CAS performed using a transfemoral approach. Patients with ≥70% asymptomatic and ≥50% symptomatic carotid stenosis, ≤80 years of age and at standard or high risk for carotid endarterectomy (CEA) are eligible for the C2R. The primary endpoint was a composite of severe access-related complications. Comparisons were made using propensity-score matched logistic regression. The mean age of the cohort was 67.6 ± 8.2 years and 1906 (35.1%) were female. Indications for CAS included 4063 (74.9%) for primary atherosclerosis. A total of 2868 (52.8%) cases underwent CAS for asymptomatic disease. Transradial access was used in 213 (3.9%) patients. The transradial cohort had lower use of general anesthesia (1.5% vs. 6.3%, p=0.007) and higher use of distal embolic protection (96.7% vs. 89.4%, p=0.0004). There were no significant differences between radial and femoral access groups in terms of a composite of major access-related complications (0% vs. 1.1%) or a composite of periprocedural stroke or death (3.3% vs. 2.4%; OR=1.4 [confidence intervals 0.6, 3.1]; p=0.42). We found no significant differences in rates of major access-related complications or periprocedural stroke or death with CAS performed using transradial compared to transfemoral access. Our results support incorporation of the transradial approach to clinical trials comparing CAS to other revascularization techniques.

PCV47 Evidence Requirements in Coverage Determinations for Reimbursement Related to Carotid Artery Stenting: A Systematic Review

This research aims to discern what evidence is sourced by payers and how often, and analyze the characteristics of evidence used in a coverage determination policy. Ascertainable standards can ensure that coverage decisions are fair, orderly, and consistent rather than arbitrary. Six coverage determinations for Carotid Artery Stenting(CAS) from Cigna, Aetna, CMS, and three Blue Cross Blue Shield plans were used to determine the quality of evidence used in coverage decisions. Evidence used was analyzed for age, study type, level of evidence, geographic information and population size from the body and abstracts of the policy references. The 245 unique articles that had PubMed identification numbers were used in the analysis. The support of CAS within the coverage determinations was mixed but all policies indicated coverage of CAS. By assigning 1 to CAS supporting articles, 0 to neutral articles, and -1 to articles with a negative conclusion to the effectiveness or safety of CAS compared to carotid enterectomy (CEA) it was calculated that the evidence supported CAS over CAE in 50% of the policies. Systematic Reviews, Society Guidelines, Prospective and non-randomized trials, literature reviews, cohort studies and case-controlled studies were more likely to support CAS over the standard of care (CEA). Randomized Controlled Trials, Meta-analysis, and Expert Opinion were more likely to come to a negative conclusion on CAS. There is a large variation of evidence selected by payers to support the coverage of CAS. This could indicate selection bias by the payers. The research did not demonstrate when awareness of a new technology led to evidence inclusion in coverage policies because age of evidence used varied so much among the payers. We can assume all payers have access to the same evidence but, the policies indicate that they only include a limited number of articles to support their coverage determinations.

Three-Month Outcome of Carotid Artery Stenting in Patients with/without Coexistent Unruptured Intracranial Aneurysms

Introduction: Safety of carotid artery stenting (CAS) in patients having carotid stenosis with coexistent unruptured intracranial aneurysms (UIAs) is rarely reported. Thus, we studied the 3-month outcome of CAS in the presence of coexistent UIAs in our institution. Methods: A retrospective analysis of patients receiving CAS at our institution from September 2011 to December 2019 was carried out. Patients were stratified into 2 groups: group of CAS with UIAs (CAS-UIA) and group of CAS without UIAs (CAS). The main complications within 3 months after stenting were TIA, ischemic stroke, symptomatic intracranial hemorrhage (sICH), rupture of UIAs, and death. The baseline characteristics and complications of the 2 groups were compared. Results: Five hundred fifty-six patients (CAS, n = 468; CAS-UIA, n = 88) were included and 604 stenting procedures were performed. More patients had hypertension in the CAS-UIA group (87.5 vs. 73.7%, p = 0.006). There was no significant difference in TIAs, ischemic stroke, sICH, and death within 3 months after stenting between the CAS and CAS-UIA groups. None of the 113 coexistent UIAs detected in 88 patients had aneurysm rupture within 3 months after CAS. Conclusions: In our large cohort of CAS patients, coexistent UIAs are not uncommon. Stenting of a carotid artery in the presence of coexistent UIAs could be conducted safely. Together with 3-month dual antiplatelet therapy, CAS did not increase the rupture risk of the coexistent UIAs within 3 months.

Thirty-Day Outcome of Carotid Artery Stenting in Elderly Patients: A Single-Center Experience

The safety of carotid artery stenting (CAS) in elderly patients is controversial. The aims of this study were to evaluate 30-day outcomes after CAS in elderly patients (≥70 years old) and to investigate risk factors for postoperative incidence of major adverse clinical events (MACE) to improve CAS safety based on clinical evidence in this specific subgroup of patients. The data set included patients who underwent CAS between 2001 and 2017 at Xuanwu Hospital, Capital Medical University. The primary outcome variable was 30-day postoperative incidence of the following MACE: death, myocardial infarction, and ipsilateral stroke. Univariate and multivariate analyses were performed to identify high-risk patients and procedural characteristics associated with MACE. A total of 1029 elderly patients who underwent CAS for carotid artery stenosis were identified and analyzed. The incidence of postoperative MACE was 3.01% (n= 31 cases [5 deaths, 24 strokes, and 2 myocardial infarctions]). After multivariate analysis, independent predictors of MACE included a family history of stroke (odds ratio [OR]= 3.817; 95% confidence interval [CI], 1.227-11.876; P= 0.021), symptomatic status (OR= 2.650; 95% CI, 1.210-5.806; P=0.015), and modified Rankin Scale score ≥3 (OR= 4.594; 95% CI, 1.708-12.352; P= 0.003). Hyperlipidemia was not an independent risk factor (OR= 1.597; 95% CI, 0.745-3.425; P=0.229). At our center, CAS was safely performed in elderly patients. A family history of stroke, symptomatic status, and modified Rankin Scale score ≥3 indicating a neurologic deficit increased the risk of 30-day postoperative MACE.

Carotid Artery Stenting and Intracranial Thrombectomy for Tandem Cervical and Intracranial Artery Occlusions.

It remains controversial whether carotid artery stenting (CAS) is needed in cases of tandem cervical internal carotid artery occlusion (cICAO) and intracranial large vessel occlusion (LVO). To investigate the efficacy and safety of CAS in combination with endovascular thrombectomy (CAS-EVT) in cICAO-LVO patients and to compare its outcomes with those of EVT without CAS (EVT-alone). We identified all patients who underwent EVT for tandem cICAO-LVO from the prospectively maintained registries of 17 stroke centers. Patients were classified into 2 groups: CAS-EVT and EVT-alone. Clinical characteristics and procedural and clinical outcomes were compared between 2 groups. We tested whether CAS-EVT strategy was independently associated with recanalization success. Of the 955 patients who underwent EVT, 75 patients (7.9%) had cICAO-LVO. Fifty-six patients underwent CAS-EVT (74.6%), and the remaining 19 patients underwent EVT-alone (25.4%). The recanalization (94.6% vs 63.2%, P=.002) and good outcome rates (64.3% vs 26.3%, P=.007) were significantly higher in the CAS-EVT than in the EVT-alone. Mortality was significantly lower in the CAS-EVT (7.1% vs 21.6%, P=.014). There was no significant difference in the rate of symptomatic intracranial hemorrhage between 2 groups (10.7 vs 15.8%; P=.684) and according to the use of glycoprotein IIb/IIIa inhibitor (10.0% vs 12.3%; P=.999) or antiplatelet medications (10.2% vs 18.8%; P=.392). CAS-EVT strategy remained independently associated with recanalization success (odds ratio: 24.844; 95% confidence interval: 1.445-427.187). CAS-EVT strategy seemed to be effective and safe in cases of tandem cICAO-LVO. CAS-EVT strategy was associated with recanalization success, resulting in better clinical outcome.

Efficacy and safety of carotid artery stenting: Experience of a single center.

Moderate and severe carotid artery stenosis in the internal carotid artery causes 10% to 15% of all strokes. The aim of this study was to evaluate the safety and short-term efficacy of carotid artery stenting (CAS) performed at a tertiary referral center. The records of patients who underwent CAS between January 2017 and May 2018 at a tertiary care center were analyzed retrospectively and a total of 145 patients were included in the study. The mean age of the patients was 70.1±8.6 years, 75.2% of the study group was male, and 37.9% had hypertension. Of the patients evaluated, 81 (55.9%) were classified as symptomatic and 64 (44.1%) were classified as asymptomatic. A percutaneous coronary intervention was performed after CAS more often in symptomatic patients (38.9%), while it was observed at the same rate both before (25.9%) and after (25.9%) CAS in the asymptomatic group, but the difference between the groups was not statistically significant. A distal embolic protection device (EPD) was used in symptomatic patients (59.2%) and in the asymptomatic group (78.7%); however, a proximal EPD was used significantly more often in symptomatic patients (45.6%) compared with asymptomatic patients. No patient death was recorded while in hospital, and stroke/transient ischemic attack (TIA) development was observed in 5 (3.4%) patients. Stroke was seen in 2 patients (2.4%) and TIA in 3 patients (3.7%) in the symptomatic group; TIA or stroke was not seen in the asymptomatic group. The results of this study revealed that CAS was a safe and practical procedure with an acceptable complication rate. In the appropriate patients, experienced interventionists can achieve good results when aggressive risk modification is applied and an EPD and optimal medical therapy are used.

Long-term Outcomes of Stenting and Endarterectomy for Symptomatic Carotid Stenosis: A Preplanned Pooled Analysis of Individual Patient Data

A pooled analysis was conducted of four randomized controlled trials with patients randomly assigned between November 2000 and July 2008. Review of the four largest randomized trials (Endarterectomy vs Angioplasty in Patients with Symptomatic Severe Carotid Stenosis [EVA-3S], Stent-Protected Angioplasty vs Carotid Endarterectomy [SPACE], International Carotid Stenting Study [ICSS], and Carotid Revascularization Endarterectomy versus Stenting Trial [CREST]) of carotid artery stenting and carotid endarterectomy (CEA) for treatment of symptomatic carotid stenosis included 4754 patients for analysis. Median follow-up ranged from 2.0 to 6.9 years. After the periprocedural period, annual rates of ipsilateral stroke per person-year were similar between the two treatments. However, the periprocedural and postprocedural stroke risks combined favored CEA with treatment differences equal to 3.2% up to 9 years. Although long-term outcomes continue to favor CEA, the similarity of postprocedural rates suggests that improvements in the periprocedural safety of carotid artery stenting could provide similar outcomes of the two procedures in the future.

Carotid Artery Stenosis

Stroke is one of the leading causes of death in the world and carotid artery stenosis is a major cause of ischaemic strokes. Symptomatic patients are often treated with either carotid endarterectomy (CEA) or carotid artery stenting (CAS). Asymptomatic patients can be treated with best medical therapy, CEA or CAS. While guidelines exist for the management of carotid artery stenosis, the results of recent studies are controversial regarding the safety of CAS compared with CEA. This review aims to outline the current guidelines while reviewing up-to- date studies and analyses. Future studies and emerging technologies are outlined in an attempt to provide an evaluation of the current data and management of this complex problem.

Long-term outcomes of stenting and endarterectomy for symptomatic carotid stenosis: a preplanned pooled analysis of individual patient data

The risk of periprocedural stroke or death is higher after carotid artery stenting (CAS) than carotid endarterectomy (CEA) for the treatment of symptomatic carotid stenosis. However, long-term outcomes have not been sufficiently assessed. We sought to combine individual patient-level data from the four major randomised controlled trials of CAS versus CEA for the treatment of symptomatic carotid stenosis to assess long-term outcomes. We did a pooled analysis of individual patient-level data, acquired from the four largest randomised controlled trials assessing the relative efficacy of CAS and CEA for treatment of symptomatic carotid stenosis (Endarterectomy versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis trial, Stent-Protected Percutaneous Angioplasty of the Carotid Artery versus Endarterectomy trial, International Carotid Stenting Study, and Carotid Revascularization Endarterectomy versus Stenting Trial). The risk of ipsilateral stroke was assessed between 121 days and 1, 3, 5, 7, 9, and 10 years after randomisation. The primary outcome was the composite risk of stroke or death within 120 days after randomisation (periprocedural risk) or subsequent ipsilateral stroke up to 10 years after randomisation (postprocedural risk). Analyses were intention-to-treat, with the risk of events calculated using Kaplan-Meier methods and Cox proportional hazards analysis with adjustment for trial. In the four trials included, 4775 patients were randomly assigned, of whom a total of 4754 (99·6%) patients were followed up for a maximum of 12·4 years. 21 (0·4%) patients immediately withdrew consent after randomisation and were excluded. Median length of follow-up across the studies ranged from 2·0 to 6·9 years. 129 periprocedural and 55 postprocedural outcome events occurred in patients allocated CEA, and 206 and 57 for those allocated CAS. After the periprocedural period, the annual rates of ipsilateral stroke per person-year were similar for the two treatments: 0·60% (95% CI 0·46-0·79) for CEA and 0·64% (0·49-0·83) for CAS. Nonetheless, the periprocedural and postprocedural risks combined favoured CEA, with treatment differences at 1, 3, 5, 7, and 9 years all ranging between 2·8% (1·1-4·4) and 4·1% (2·0-6·3). Outcomes in the postprocedural period after CAS and CEA were similar, suggesting robust clinical durability for both treatments. Although long-term outcomes (periprocedural and postprocedural risks combined) continue to favour CEA, the similarity of the postprocedural rates suggest that improvements in the periprocedural safety of CAS could provide similar outcomes of the two procedures in the future. None.