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Pros and cons of carotid stenting versus carotid endarterectomy delineated

Reuters Health • The Doctor's Channel Daily Newscast

NEW YORK (Reuters Health) – For patients with significant carotid artery stenosis, undergoing carotid artery stenting (CAS) carries a higher risk of death or stroke than does carotid endarterectomy (CEA). On the other hand, the risk of MI or cranial nerve injury is higher with endarterectomy than with stent placement, according to a new meta-analysis.

“This meta-analysis supports a general principle in medicine — therapy needs to be individualized,” senior investigator Dr. Deepak L. Bhatt said in emailed comments. “Some patients are going to be better served by carotid stenting, while others will be served better by carotid surgery.”

In order to evaluate the periprocedural and longer-term benefits and harms of CAS compared with CEA, Dr. Bhatt with Brigham and Women’s Hospital and VA Boston Healthcare System, Massachusetts, and colleagues identified 263 randomized clinical trials comparing the two approaches. Thirteen trials randomizing 7477 participants were included in the analysis.

As reported in the Archives of Neurology published online October 11, the risk of the composite periprocedural outcome of death, MI, or stroke was 5.68% with CAS compared to 4.73% with CEA – a 31% higher risk with CAS.

Specifically, the corresponding rates for periprocedural death or stroke were 5.50% vs 3.81%, respectively (a 65% increase in risk), and for any periprocedural stroke, 4.97% vs 3.19%, respectively (67% increase).

“However, CEA as compared with CAS was associated with a 122% increase in the risk of periprocedural MI (1.16% vs 0.27%, respectively),” Dr. Bhatt and colleagues found.

Longer-term outcomes followed a similar pattern. Carotid artery stenting as compared with CEA was associated with a 24% increase in the risk for death or stroke and a 48% increase in the risk for any stroke.

The risk of cranial nerve injury, which only occurred in the periprocedural period, was 85% lower with CAS as compared with CEA.

What message can doctors take home? asks an editorial. “Both procedures showed a relatively low rate of serious complications,” write Dr. Louis R. Caplan of Beth Israel Deaconess Medical Center in Boston and Dr. Thomas G. Brott with the Mayo Clinic, Jacksonville, Florida. “Surgery is superior concerning some outcomes; stenting seems to have advantages in others. Each has its own frequency of complication.”

The choice of procedure depends in part on the patient’s underlying risk of MI and stroke, Dr. Bhatt advised. “For example, patients at high risk of heart attack may be better served getting a carotid stent, which is minimally invasive, as opposed to taking on the risks of surgery.”

Another factor, he added, is “the local expertise of the doctor performing the carotid stent (which is a newer procedure) or the carotid surgery. In a center without much experience performing carotid stenting, surgery would likely be a better option.”

Dr. Bhatt concluded, “Ongoing research will help refine this decision making.”

Arch Neurol 2010.