Rajbeer Singh Sangha, MD

Mas JL, Arquizan C, Calvet D, Viguier A, Albucher JF, Piquet P, et al. Long-Term Follow-Up Study of Endarterectomy Versus Angioplasty in Patients With Symptomatic Severe Carotid Stenosis Trial. Stroke. 2014

The authors of this paper looked at comparing the long-term benefit–risk balance of carotid stenting versus endarterectomy for symptomatic carotid stenosis. In recent landmark trials, carotid stenting has been associated with a higher risk of procedural stroke or death compared to endarterectomy. It should be noted that this difference was mainly driven by mild and non-disabling strokes. The authors go on to point out that, it is crucial to know whether stenting is as effective as endarterectomy to prevent stroke recurrence in the long term. This study looked at long-term efficacy of the two treatments in terms of prevention of recurrent ipsilateral stroke beyond the procedural period and incidence of severe carotid restenosis or occlusion.

A total of 527 patients were enrolled from November 2000 to September 2005, at which time the safety committee recommended to stop enrollment for safety reasons. Outcomes (from January 2008 up to December 2012) were established retrospectively using complementary methods. During a median follow-up of 7.1 years (interquartile range, 5.1 to 8.8 years, maximum 12.4 years), the primary endpoint occurred in 30 patients in the stenting group compared to 18 patients in the endarterectomy group. The hazard ratio (HR) for stenting versus endarterectomy was 1.85 (95% CI 1.00–3.40; p=0.04). No difference was observed between treatment groups in the rates of ipsilateral stroke beyond the procedural period, severe carotid restenosis (>= 70%) or occlusion, death, myocardial infarction and revascularization procedures.

This article certainly confirms what has been seen in previous RCT’s, which is that the excess risk of stroke associated with stenting was driven by a significant increased risk of procedural non disabling strokes. Furthermore, no significant difference was noted in the occurrence of post-procedural ipsilateral strokes. Though the authors note that the long term differences between endarterectomy and stenting are only marginally different, they acknowledge that endarterectomy is clearly the favored option. This is based on the fact that procedural stroke risk is higher in stenting. An important question for the authors may be whether the early non-disabling strokes pose other long-term risks such as cognitive impairment or impaired quality of life.