Lower Stroke and Death Rates With Carotid Endarterectomy vs Carotid Stenting

December 03, 2008

December 3, 2008 (Worcester, Massachusetts) — A large study comparing carotid endarterectomy and carotid artery stenting showed the less invasive interventional approach resulted in higher in-hospital mortality and postoperative stroke rates as well as more expensive hospital costs [1].

Among symptomatic patients with carotid artery stenosis, for example, there was a fourfold increased risk of in-hospital mortality and a twofold increased risk of postoperative stroke compared with the surgical approach, report investigators.

"These observations indicate that the anticipated forthcoming results of randomized controlled trials will be of critical importance in determining the future applicability of carotid artery stenting in patients with carotid artery stenosis," writes first author Dr James McPhee (University of Massachusetts Medical School) and colleagues in the December 2008 issue of the Journal of Vascular Surgery.

Those studies include the National Institutes of Health (NIH)–sponsored Carotid Revascularization Endarterectomy vs Stenting Trial (CREST) and International Carotid Stenting Study (ICSS). CREST investigators completed enrollment this past summer and results are expected in 2009. The study includes 2511 asymptomatic and symptomatic patients who are not at high risk for surgery, whereas the ICSS study is a head-to-head comparison of carotid stenting and endarterectomy in approximately 1700 asymptomatic patients with carotid stenosis.

Many Studies and Different Results

In addition to the anticipated CREST and ICSS studies, a number of head-to-head comparisons between carotid artery stenting and endarterectomy have been published in recent years. Conflicting data from clinical trials, however, as well as from single-center and population-based studies, have created some controversy about the indications for carotid stenting.

Two carotid-artery stenting studies--the Stent-Supported Percutaneous Angioplasty of the Carotid Artery versus Endarterectomy (SPACE) [2] and Endarterectomy versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis (EVA-3S) [3] were published in 2006, and both showed stenting to be inferior to endarterectomy.

These findings, which one interventionalist previously described as an "earthquake" in the field of carotid stenting, contrasted with data from the Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy (SAPPHIRE) trial, a study that compared carotid stenting using distal embolic protection with carotid endarterectomy in patients at high surgical risk [4]. Based on the findings from SAPPHIRE, the Food and Drug Administration approved the use of carotid stenting in patients with high-grade symptomatic stenosis who are at high operative risk.

In this analysis, McPhee and colleagues sought to compare clinical outcomes and resource utilization with the two treatment approaches for carotid artery stenosis on the national level. They obtained 2005 discharge data, the first year a code was available for carotid stenting, from a database of 20% of all nonfederal hospitals in the US.

In this one-year period, an estimated 135 701 patients underwent either carotid endarterectomy or stenting, and a majority of these individuals, more than 122 000, underwent carotid endarterectomy. In addition, most patients undergoing revascularization were asymptomatic. Of the 10 496 symptomatic patients revascularized, 9380 received carotid endarterectomy and 1116 underwent carotid stenting.

Results showed higher in-hospital and postoperative stroke rates among those undergoing carotid stenting. The mortality difference between the two treatment arms was more pronounced among symptomatic patients, as was the cost of the procedure and length of hospital stay.

Postoperative Outcomes and Resource Utilization by Endarterectomy and Stenting

Outcome Carotid endarterectomy Carotid artery stenting p
All patients      
In-hospital mortality, % 0.57 1.1 0.004
Postoperative stroke, % 1.1 1.8 0.0004
Length of stay, median (range), d 2 (0–117) 1 (0–66) <0.0001
Total hospital charges, median, $ 17 658 30 396 <0.0001
Asymptomatic carotid artery stenosis patients (n=122 986)      
In-hospital mortality, % 0.38 0.57 0.18
Postoperative stroke, % 0.88 1.6 0.001
Length of stay, median (range), d 1 (0–110) 1 (0–53) <0.0001
Total hospital charges, median, $ 16 956 28 853 <0.0001
Symptomatic carotid artery stenosis patients (n=10 495)      
In-hospital mortality, % 1.4 4.6 0.0002
Postoperative stroke, % 2.5 4.1 0.15
Length of stay, median (range), d 4 (1–67) 5 (0–66) <0.0001
Total hospital charges, median, $ 29 894 49 535 <0.0001

Investigators said the new data are not an indictment of carotid artery stenting, but its role needs to be better defined (eg, in asymptomatic vs symptomatic patients), and future studies will help to do this. Over time, they expect the treatment gap between the two approaches to narrow, particularly as operators gain technical experience and future trials identify patient populations for the different procedures.

Speaking with heartwire, senior investigator Dr Mohammed Eslami (University of Massachusetts Medical School), who performs stenting, said it is a procedure that needs to be performed cautiously and selectively.

"If you have an asymptomatic patient coming to you for a carotid stenting procedure, and that patient dies, there is something wrong with that," he said.

In May 2007, the US Centers for Medicare and Medicaid Services (CMS) said it would not expand Medicare coverage of carotid stenting to asymptomatic subjects or to subjects with less severe blockages, a decision it reiterated this past October.

  1. McPhee JT, Schanzer A, Messina LM, Eslami MH. Carotid artery stenting has increased rates of postprocedure stroke, death, and resource utilization than does carotid endarterectomy in the United States, 2005. J Vasc Surg 2008; DOI: 10.1016/j.jvs.2008.07.017. Available at: a. Abstract

  2. Space Collaborative Group. 30-day results from the SPACE trial of stent-protected angioplasty versus carotid endarterectomy in symptomatic patients: a randomised non-inferiority trial. Lancet 2006; 368:1239-47. Abstract

  3. Mas JL, Chatellier G, Beyssen B. Endarterectomy versus stenting in patients with symptomatic severe carotid stenosis. N Engl J Med 2006; 355:1660-71. Abstract

  4. Yadav JS, Wholey MH, Kuntz RE. Protected carotid-artery stenting versus endarterectomy in high-risk patients. N Engl J Med 2004; 351:1493-50. Abstract

  5. face="Verdana" size="1">The complete contents of Heartwire , a professional news service of WebMD, can be found at www.theheart.org, a Web site for cardiovascular healthcare professionals.


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