Carotid Stenting Within First Week of Symptoms Carries Higher Risk Than CEA

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When performed within the first 7 days of ischemic symptoms, carotid artery stenting (CAS) carries a higher risk of death or stroke at 30 days than carotid endarterectomy (CEA), but the difference is ameliorated with increasing time from the qualifying event. Data from a pooled analysis of 3 separate studies were presented June 9, 2012, at the annual meeting of the Society for Vascular Surgery in Washington, DC.

Barbara Rantner, MD, PhD, of Innsbruck Medical University (Innsbruck, Austria), and colleagues looked at data on the timing of carotid intervention from 2,839 symptomatic patients pooled from 3 randomized trials that compared CAS with CEA: EVA-3S, SPACE, and ICSS. The overall 30-day rate of stroke or death was twice as high in CAS patients (7.7% vs. 3.8%; RR 2.0; 95% CI 1.5-2.7). This disparity was greatest if the intervention was performed within 7 days of qualifying ischemic symptoms, growing less over time (table 1).

Table 1. Thirty-day Stroke/Death Rates by Timing of Intervention

These rates were independent of age, sex, source trial, and qualifying event. Later CEA somewhat increased the risk of perioperative stroke and death compared with CEA within 7 days, from an adjusted RR of 1.2 at 8 to 14 days (95% CI 0.3-4.4) to 1.4 beyond 14 days (95% CI 0.4-4.4), though these results missed statistical significance.

“We found that the increase in risk of CAS compared with CEA appears greatest in patients treated within 7 days of symptoms,” the researchers conclude.

But in a telephone interview with TCTMD, Issam D. Moussa, MD, of the Mayo Clinic (Jacksonville, FL), took issue with some basic assumptions of the analysis, noting that interventionalists who performed CAS in both EVA 3S and ICSS were very inexperienced, and both trials featured only voluntary use of embolic protection, leading to variable rates of the practice.

“So you’re already starting from data that do not really apply, for example, to the CREST trial, where there was no difference between carotid stenting and CEA in the combined endpoint [of death, MI, or stroke],” he told TCTMD.

CEA Finding ‘Counterintuitive’

Nevertheless, increased risk within the first week of ischemic symptoms makes sense. “When people are symptomatic and come in with a stroke, the plaque is friable and ulcerated and thrombotic,” Dr. Moussa said. “The risk is higher than if you do stenting later, that’s a well-known fact. But that also applies to CEA. The earlier you intervene, the higher the perioperative rate. Here they did not find that, so it’s counterintuitive and counter to prior knowledge on the topic.”

In an e-mail communication with TCTMD, study coauthor Gustav Fraedrich, MD, of Innsbruck Medical University, disagreed regarding Dr. Moussa’s assertion regarding operator experience. “In EVA-3S and SPACE, there was no correlation between CAS experience and results, [and] in ICSS they were experienced,” he said. “In our analysis of the original data from all 3 studies, the experience of the operator or center did not influence the complication rate.”

Furthermore, noted Dr. Rantner in an e-mail communication with TCTMD, “the explanation for the fact that CAS might be especially dangerous in the early days after neurological symptoms is that the ruptured plaque is very vulnerable and catheter passage is therefore hazardous. Early surgery, on the other hand, does not carry a higher risk compared with delayed surgery. This is what we learned from several recent studies (pooled data from NASCET and ECST, for example).”

Dueling Conclusions

Dr. Moussa noted that adding CREST data to the analysis would have improved the validity of the study. Regardless, “this reinforces that these patients are high risk and that stenting or endarterectomy should probably be avoided for the first week, especially if they’re inexperienced operators,” he said.

Dr. Rantner came to a slightly different conclusion. “We assume that early CAS might have a higher risk for periprocedural complications. On the other hand, the early days after an ischemic event are those with the highest risk for a recurrent ischemic event in the natural course, so postponing CAS might not be reasonable,” she said. “Surgery, in comparison, can be safely performed close to the initial ischemic event, so this might influence the decision in clinical practice.”

Dr. Fraedrich concurred. “It is well known that even if the stroke rate is higher in the first two weeks, the profit of avoiding strokes is [even] higher,” he said. “In my opinion CEA should be the preferred treatment for symptomatic patients because the patients profit from early intervention and they are often older—both conditions that carry a two- to three-fold risk with CAS.”

 

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Source:
Rantner B, Fraedrich G, Goebel G, et al. The risk of carotid artery stenting compared with carotid endarterectomy is greatest in patients treated within 7 days of symptoms. Paper presented at: 66th Vascular Annual Meeting of the Society for Vascular Surgeons; Washington, DC. June 9, 2012.

 

 

Related Stories:

• SVS Registry Finds Surgery Superior to Stenting in Older Carotid Patients
• CREST Analysis: Restenosis Rates Similar at 2 Years for Carotid Stenting, Surgery
• CREST QOL Substudy: Early Advantage with Carotid Stenting Disappears Long-Term

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