Carotid Stenting vs. Endarterectomy: Longer-Term Outcomes
Among patients without periprocedural complications, adverse outcomes at 2 years did not differ for stenting and endarterectomy.
Both the SPACE and EVA-3S trials are randomized comparisons of carotid-artery stenting and carotid endarterectomy in patients with symptomatic carotid stenosis. Previously, 30-day outcomes from these trials were reported (JW Oct 24 2006 and JW Oct 18 2006). Now, longer-term outcomes have been published.
In SPACE, which involved about 1200 patients, the 30-day incidence of ipsilateral stroke or all-cause death was similar in the two groups (6.8% and 6.3%). During the subsequent 23 months, 2% of patients in each group suffered ipsilateral ischemic strokes. This study was partially supported by stent manufacturers.
In EVA-3S, which involved 527 patients, the 30-day incidence of stroke or death was significantly higher with stenting than with endarterectomy (9.6% vs. 3.9%). However, during an additional 3.5 years of follow-up, ipsilateral ischemic stroke occurred in only 4 patients (about 2%) in each group.
Comment: In the SPACE trial, researchers noted little difference between carotid stenting and endarterectomy for either short-term or intermediate-term outcomes. In EVA-3S, outcomes were worse with stenting during the periprocedural period (for reasons that have been debated, but remain unclear); beyond 30 days, however, new strokes occurred with similar frequency in the stent and endarterectomy groups. Taken together, these trials suggest that stenting and endarterectomy afford equal protection against stroke in the long run, assuming that patients initial procedures are uneventful; however, we still need a better understanding of which patients experience procedural complications and how to avoid them. The ongoing CREST trial, in which 2500 patients are enrolled, hopefully will answer these questions.
Published in Journal Watch General Medicine October 9, 2008
Eckstein H-H et al. Results of the Stent-Protected Angioplasty versus Carotid Endarterectomy (SPACE) study to treat symptomatic stenoses at 2 years: A multinational, prospective, randomised trial. Lancet Neurol 2008 Oct; 7:893.
Mas J-L et al. Endarterectomy Versus Angioplasty in patients with Symptomatic Severe carotid Stenosis (EVA-3S) trial: Results up to 4 years from a randomised, multicentre trial. Lancet Neurol 2008 Oct; 7:885.
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