Protected Carotid-Artery Stenting versus Endarterectomy in High-Risk Patients

Yadav, Jay S.; Wholey, Mark H.; Kuntz, Richard E.; Fayad, Pierre; Katzen, Barry T.; Mishkel, Gregory; Bajwa, Tanvir; Whitlow, Patrick L.; Strickman, Neil E.; Jaff, Michael R.; Popma, Jeffrey J.; Snead, D.; Cutlip, Donald E.; Firth, Brian G.; Ouriel, Kenneth

doi:10.1056/nejmoa040127

Cited by 2,573 publications

(696 citation statements)

References 32 publications

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“…Several randomized studies and registries have shown similar outcomes when compared with carotid endarterectomy in high-risk populations (17,18). Emboli are known to be associated with a high neurological complication rate and are also recognized as a potential cause of periprocedural stroke during CAS.…”

Section: Discussionmentioning

confidence: 92%

Observation of the embolus protection filter for carotid artery stenting

et al. 2009

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Section: Discussionmentioning

confidence: 92%

Observation of the embolus protection filter for carotid artery stenting

et al. 2009

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“…After removing duplicates, we screened the titles and abstracts of 1126 publications. A total of 48 publications underwent full-text review, of which 10 reports [13][14][15][29][30][31][32][33][34][35] of 4 RCTs reported relevant outcomes among asymptomatic patients. In addition, the corresponding author of 1 RCT 36 provided information on asymptomatic patients on request, yielding a total of 11 reports of 5 RCTs in our review.…”

Section: Search Resultsmentioning

confidence: 99%

“…In 3 RCTs, interventionists were required to have a minimum level of experience to participate in the study. [13][14][15][29][30][31][32][33][34][35] The median duration of follow-up ranged from 30 days to 10 years.…”

Section: Study Characteristicsmentioning

confidence: 99%

Carotid Stenting Versus Endarterectomy for Asymptomatic Carotid Artery Stenosis

Moresoli

Habib

Reynier

et al. 2017

Stroke

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Background and Purpose— There is no consensus on the comparative efficacy and safety of carotid artery stenting (CAS) versus carotid endarterectomy (CEA) in patients with asymptomatic carotid artery stenosis. To evaluate CAS versus CEA in asymptomatic patients, we conducted a systematic review and meta-analysis of randomized controlled trials. Methods— We systematically searched EMBASE, PubMed, MEDLINE, and the Cochrane Library for randomized controlled trials comparing CAS to CEA in asymptomatic patients using a pre-specified protocol. Two independent reviewers identified randomized controlled trials meeting our inclusion/exclusion criteria, extracted relevant data, and assessed quality using the Cochrane risk of bias tool. Random effects models with inverse-variance weighting were used to estimate pooled risk ratios (RRs) comparing the incidences of periprocedural and long-term outcomes between CAS and CEA. Results— We identified 11 reports of 5 randomized controlled trials for inclusion (n=3019) asymptomatic patients. The pooled incidences of any periprocedural stroke (RR, 1.84; 95% confidence interval [CI], 0.99–3.40), periprocedural nondisabling stroke (RR, 1.95; 95% CI, 0.98–3.89), and any periprocedural stroke or death (RR, 1.72; 95% CI, 0.95–3.11) trended toward an increased risk after CAS. We could not rule out clinically significant differences between treatments for long-term stroke (RR, 1.24; 95% CI, 0.76–2.03) and the composite outcome of periprocedural stroke, death or myocardial infarction, or long-term ipsilateral stroke (RR, 0.92; 95% CI, 0.70–1.21). Conclusions— Although uncertainty surrounds the long-term outcomes of CAS versus CEA, the potential for increased risks of periprocedural stroke and periprocedural stroke or death with CAS suggests that CEA is the preferred option for the management of asymptomatic carotid stenosis.

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“…SAPPHIRE (Stenting and Angioplasty With Protection in Patients at High Risk for Endarterectomy Investigators) included asymptomatic patients with >80% stenosis and found that CAS was associated with a lower risk of the composite outcome of stroke, MI, or death at 1 year than CEA (9.9% versus 21.5%). 22 These generalizabilities of the results are limited by the lack of a medical control arm and the high complication rates in both treatment arms that may exceed risk associated with medical therapy alone. Randomized trials of CAS compared with CEA have been performed, but the studies included both symptomatic and asymptomatic patients and did not include a control arm receiving medical therapy alone.…”

Section: Primary Stroke Prevention In Asymptomatic Carotid Stenosismentioning

confidence: 99%

Stroke Caused by Extracranial Disease

Barrett

Brott

2017

Circulation Research

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Extracranial internal carotid artery atherosclerotic occlusive disease is a common ischemic stroke mechanism. Vascular risk factor control remains the cornerstone of stroke prevention in patients with both asymptomatic and symptomatic carotid occlusive diseases. Intensive medical therapy refers to the contemporary approach of antiplatelet therapy, blood pressure control, low-density lipoprotein reduction, and lifestyle modification to reduce stroke risk. Carotid revascularization with endarterectomy or angioplasty and stenting are established treatments for patients with symptomatic carotid stenosis ≥70%. Previously accepted ischemic stroke preventative strategies, such as carotid revascularization for asymptomatic carotid stenosis, require reassessment given advances in both medical therapy and surgical techniques. The purpose of this review is to describe contemporary approaches to the management of extracranial carotid atherosclerotic occlusive disease and the basis of these recommendations. Results from recently published clinical trials will be highlighted in addition to updated information from clinical trials addressing knowledge gaps in prevention of stroke caused by extracranial disease. (Circ Res. 2017;120:496-501.

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Protected Carotid-Artery Stenting versus Endarterectomy in High-Risk Patients

Abstract: Among patients with severe carotid-artery stenosis and coexisting conditions, carotid stenting with the use of an emboli-protection device is not inferior to carotid endarterectomy.

Cited by 2,573 publications

References 32 publications

Observation of the embolus protection filter for carotid artery stenting

Observation of the embolus protection filter for carotid artery stenting

Carotid Stenting Versus Endarterectomy for Asymptomatic Carotid Artery Stenosis

Stroke Caused by Extracranial Disease

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