How does the prognosis of atherosclerotic disease of the carotid artery vary following CEA or stenting?

Updated: Sep 29, 2021
  • Author: Jake F Hemingway, MD; Chief Editor: Vincent Lopez Rowe, MD  more...
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The Endarterectomy Versus Stenting in Patients With Symptomatic Severe Carotid Stenosis (EVA-3S) trial revealed a higher stroke and death rate with carotid artery stenting (CAS); however, cerebral protection was not uniformly used, and dual antiplatelet therapy was not initiated on all patients. [4]

A meta-analysis revealed that protected (use of an embolic protection wire) CAS was associated with an 8.2% rate of stroke or death at 30 days, compared with 6.2% for surgery [5] ; however, the rates of disabling stroke or death within this period were not significantly different between the two groups.

Meier et al conducted a systematic review and meta-analysis of 11 randomized controlled clinical trials to evaluate the relative short-term safety and intermediate-term efficacy of CEA versus CAS. [6] CEA carried a lower risk of periprocedural mortality or stroke than CAS did, mainly because of a decreased risk of stroke. However, the risk of death and the composite endpoint of mortality or disabling stroke did not differ significantly between the two procedures. In addition, the odds of periprocedural myocardial infarction (MI) or cranial nerve injury (CNI) were higher among the CEA group as compared with the CAS group. In the intermediate term, the risk of stroke or death did not differ significantly between the two.

Numerous studies, including the Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy (SAPPHIRE) trial, have found that CAS is not inferior to CEA at 1 year. Published long-term results show no significant difference between groups in the prespecified secondary endpoint trial, a composite at 3 years of death, stroke, or MI within 30 days of the procedure (or death or ipsilateral stroke between 31 and 1080 days). [7]

A study by Illuminati et al suggested that with regard to the timing of CEA, previous or simultaneous CEA in patients with unilateral severe asymptomatic carotid stenosis (>70%) undergoing coronary artery bypass grafting (CABG) was better able to prevent stroke than delayed CEA was. [8] The overall surgical risk was not increased.

A study by Brown et al suggested that the risk of external carotid artery occlusion may be lower with CEA than it would be with CAS, though such occlusion after CAS was still uncommon overall (~4%) and was not associated with in-stent restenosis. [9]

The Carotid Revascularization Endarterectomy vs Stenting Trial (CREST) evaluated the outcomes of 2502 patients with symptomatic or asymptomatic carotid stenosis after undergoing CAS or CEA, and found that the risk of stroke, MI, or death was similar between the two procedures. [10]

Although there was no difference in the primary outcome of CREST, there was a higher risk of periprocedural stroke in the group who underwent CAS, whereas there was a higher risk of MI in the group undergoing CEA. [10]  Additional analysis, however, indicated that stroke had an adverse long-term effect on quality-of-life measures, whereas MI did not. Further study of the CREST data showed that 4-year mortality was significantly higher in patients who had a stroke after intervention (21.1% vs 11.6%). [11]

Whereas CNI occurred in 4.6% of the CREST patients who underwent CEA, there was a 80% rate of resolution at 1 year, and there was no statistical difference in health-related quality-of-life outcomes between patients who had CNI and those who did not. [12]

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