Percutaneous transluminal balloon angioplasty and stenting for carotid artery stenosis

Bonati, Leo H.; Lyrer, Philippe; Ederle, Jörg; Featherstone, Roland L.; Brown, Martin M.

doi:10.1002/14651858.cd000515.pub4

Cited by 159 publications

(186 citation statements)

References 71 publications

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“…In an analysis of CREST, age also significantly modified the risk of stenting versus endarterectomy, 53 whereas a pooled analysis of the data from ICSS with data from EVA-3S and SPACE, as well as a meta-analysis of all the existing trials, have confirmed that patients over the age of 70 years have a higher risk of stroke or death with stenting, but patients below the age of 70 have a similar risk with stenting compared with endarterectomy. 58,59 The analysis of the risk of baseline and procedural-related factors in ICSS showed that the use of an open-cell stent conferred higher risk than use of a closed-cell stent (RR 1.92, 95% CI 1.11 to 3.33), but the use of a cerebral protection device did not modify the risk. Although this was not a randomised comparison, the findings are in keeping with results from the SPACE study and large observational studies.…”

Section: Implications For Health Carementioning

confidence: 99%

Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): a randomised controlled trial with cost-effectiveness analysis

Featherstone

Dobson

Ederle

et al. 2016

Health Technol Assess

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BackgroundCarotid artery stenting (CAS) is an alternative to carotid endarterectomy (CEA) for the treatment of carotid stenosis, but safety and long-term efficacy were uncertain.ObjectiveTo compare the risks, benefits and cost-effectiveness of CAS versus CEA for symptomatic carotid stenosis.DesignInternational, multicentre, randomised controlled, open, prospective clinical trial.SettingHospitals at 50 centres worldwide.ParticipantsPatients older than 40 years of age with symptomatic atheromatous carotid artery stenosis.InterventionsPatients were randomly allocated stenting or endarterectomy using a computerised service and followed for up to 10 years.Main outcome measuresThe primary outcome measure was the long-term rate of fatal or disabling stroke, analysed by intention to treat (ITT). Disability was assessed using the modified Rankin Scale (mRS). A cost–utility analysis estimating mean costs and quality-adjusted life-years (QALYs) was calculated over a 5-year time horizon.ResultsA total of 1713 patients were randomised but three withdrew consent immediately, leaving 1710 for ITT analysis (853 were assigned to stenting and 857 were assigned to endarterectomy). The incidence of stroke, death or procedural myocardial infarction (MI) within 120 days of treatment was 8.5% in the CAS group versus 5.2% in the CEA group (72 vs. 44 events) [hazard ratio (HR) 1.69, 95% confidence interval (CI) 1.16 to 2.45;p = 0.006]. In the analysis restricted to patients who completed stenting, age independently predicted the risk of stroke, death or MI within 30 days of CAS (relative risk increase 1.17% per 5 years of age, 95% CI 1.01% to 1.37%). Use of an open-cell stent conferred higher risk than a closed-cell stent (relative risk 1.92, 95% CI 1.11 to 3.33), but use of a cerebral protection device did not modify the risk. CAS was associated with a higher risk of stroke in patients with an age-related white-matter changes score of 7 or more (HR 2.98, 95% CI 1.29 to 6.93;p = 0.011). After completion of follow-up with a median of 4.2 years, the number of patients with fatal or disabling stroke in the CAS and CEA groups (52 vs. 49), and the cumulative 5-year risk did not differ significantly (6.4% vs. 6.5%) (HR 1.06, 95% CI 0.72 to 1.57;p = 0.776). Stroke of any severity was more frequent in the CAS group (15.2% vs. 9.4% in the CEA group) (HR 1.712, 95% CI 1.280 to 2.300;p < 0.001). There was no significant difference in long-term rates of severe carotid restenosis or occlusion (10.8% in the CAS group vs. 8.6% in the CEA group) (HR 1.25, 95% CI 0.89 to 1.75;p = 0.20). There was no difference in the distribution of mRS scores at 1-year, 5-year or final follow-up. There were no differences in costs or QALYs between the treatments.LimitationsPatients and investigators were not blinded to treatment allocation. Interventionists’ experience of stenting was less than that of surgeons with endarterectomy. Data on costs of managing strokes were not collected.ConclusionsThe functional outcome after stenting is similar to endarterectomy, but stenting is associated with a small increase in the risk of non-disabling stroke. The choice between stenting and endarterectomy should take into account the procedural risks related to individual patient characteristics. Future studies should include measurement of cognitive function, assessment of carotid plaque morphology and identification of clinical characteristics that determine benefit from revascularisation.Trial registrationCurrent Controlled Trials ISRCTN25337470.FundingThis project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 20, No. 20. See the NIHR Journal Library website for further project information. Further funding was provided by the Medical Research Council, Stroke Association, Sanofi-Synthélabo and the European Union.

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Section: Implications For Health Carementioning

confidence: 99%

Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): a randomised controlled trial with cost-effectiveness analysis

Featherstone

Dobson

Ederle

et al. 2016

Health Technol Assess

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“…Furthermore, the proportion of patients ineligible for CAS may be higher in the elderly than in younger people. Thus, there have been numerous reports recommending CEA over CAS in the elderly, especially those aged 70 years or over [10][11][12]. Therefore, although the proportion of patients with a carotid stenotic lesion treated by CAS is expected to continue to increase in the future, it appears that there will also be a continuous need for CEA, especially for the elderly.…”

Section: Discussionmentioning

confidence: 99%

“…For such patients, adequate preoperative assessment of the general condition and subsequent perioperative management based on the assessment findings are crucial. If these procedures are not followed, the superiority and necessity of CEA in the elderly, as favorably described in many reports [10][11][12], cannot be guaranteed. Furthermore, even the evidence on the superiority of CEA in the elderly can be disputed.…”

Section: Discussionmentioning

confidence: 99%

“…In particular, there are many reports on the use of CEA in the elderly population [6][7][8][9]. Indeed, CEA is still used for elderly patients, with some reports indicating CEA as a better treatment option for this patient group [10][11][12]. However, it remains that elderly patients represent a high-risk group with well-documented perioperative complications [13].…”

Section: Introductionmentioning

confidence: 99%

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Carotid Endarterectomy for Patients over 80 Years Old

Yamada¹,

Ohnishi²,

Kuga³

et al. 2016

J Neurol Neurosci

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Objective: Carotid endarterectomy (CEA) is one of the surgical treatments for carotid artery stenosis. While a large clinical trial showed that advanced age is a risk factor for CEA, other studies reported contradictory results. The aim of this study was to evaluate the outcomes of CEA in patients aged over 80. Methods:Patients who underwent CEA between January 2012 and June 2015 in our hospital were included, and were divided into either the high age group (>80 years old) or standard group (<80 years old). CEA was the firstline surgical treatment, instead of carotid artery stenting (CAS), for all eligible cases, except where patients were not deemed amenable to general anesthesia or at patients' request not to undergo CEA. Patient background and perioperative complications were assessed and compared statistically between the high age group and standard group.Results: Of a total of 127 patients, 20 (15.7%) were in the high age group. No significant differences in patient background were obtained between the high age group and standard group. Four (20%) cases in the high age group had perioperative complications which were all transient. No significant differences in perioperative complications were obtained between the high age group and standard group Conclusions: It is possible for CEA to be performed safely in the elderly, provided adequate preoperative assessment of the general condition and perioperative management of patients are carried out. We recommend that CEA should not be avoided as a treatment option in the elderly, based solely on patient age.

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“…CAS tended to be more efficacious at younger ages, and CEA was more efficacious in older subjects. Updated Cochrane collaboration review of long‐term outcome comparisons between CAS and CEA demonstrated that CAS was associated with an increased risk of periprocedural stroke or death compared with CEA 44. However, this excess risk appeared to be limited to older patients.…”

Section: Lessons Learned From Carotid Artery Stentingmentioning

confidence: 99%

Choice and Selection of Treatment Modalities for Cardiac Patients: An Interventional Cardiology Perspective

Agarwal

Tuzcu

Kapadia

2015

JAHA

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Percutaneous transluminal balloon angioplasty and stenting for carotid artery stenosis

Cited by 159 publications

References 71 publications

Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): a randomised controlled trial with cost-effectiveness analysis

Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): a randomised controlled trial with cost-effectiveness analysis

Carotid Endarterectomy for Patients over 80 Years Old

Choice and Selection of Treatment Modalities for Cardiac Patients: An Interventional Cardiology Perspective

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