Lancet: Carotid stenting should be avoided in older patients

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The risk and harms of carotid stenting compared with endarterectomy decrease with younger age, and stenting is best avoided in patients age 70 and older, according to the results of a meta-analysis conducted by the Carotid Stenting Trialists Collaboration (CSTC) and published in the Sept. 10 issue of the Lancet.

“Results from randomized controlled trials have shown a higher short-term risk of stroke associated with carotid [artery] stenting (CAS) than with carotid endarterectomy (CEA) for the treatment of symptomatic carotid stenosis,” the authors wrote. “However, these trials were underpowered for investigation of whether carotid artery stenting might be a safe alternative to endarterectomy in specific patient subgroups.”

Martin M. Brown, MD, of the National Hospital for Neurology and Neurosurgery in London, and colleagues from the CSTC performed a meta-analysis using three previously conducted randomized controlled trials—EVA-3S (Endarterectomy versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis), SPACE (Stent-Protected Angioplasty versus Carotid Endarterectomy) and ICSS (International Carotid Stenting Study).

The meta-analysis looked at 3,454 patients who were randomized to the three aforementioned trials—1,725 patients assigned to CAS were analyzed by intention to treat 120 days post-randomization, 1,708 patients were randomized to receive CAE.

The researchers used a combination of stroke or death as the short-term outcomes and disabling stroke or death, all-cause mortality, stroke, MI, hematoma and severe wound infection as secondary outcomes during the trial.

Patient characteristics were similar in both the CAS and CEA groups.  In the CAS arm, patients had a mean age of 69.3, 71 percent were male, 23 percent had diabetes and 72 percent hypertension. CEA patients had an average age of 69.7, 72 percent were male, 25 percent had diabetes and 73 percent hypertension.

The population of patients with moderate (50 to 69 percent) carotid stenosis was greatest in the SPACE trial compared with the EVA-ES or ICSS trials, 38 percent, 7 percent and 10 percent, respectively.

In a pooled analysis results showed that the primary outcome occurred at a rate of 8.9 percent in the CAS arm compared to 5.8 percent in the CEA arm. Rates of all-cause mortality were 1.9 percent in the CAS arm versus 1.3 percent in the CEA arm. Additionally, stroke occurred at a rate of 8.2 percent in the CAS arm compared with 4.9 percent in the CEA arm.

The researchers found that the 120-day risk of stroke or death in patients younger than 70 were similar in both groups; however, the risk of stroke and death was twice that when CEA was used.

The risk estimates of stroke or death within 30 days of procedure in patients younger than 70 were 5.1 percent in the CAS group compared to 4.5 percent in the CEA group. These rates for those 70 and over were 10.5 percent versus 4.4 percent, respectively.

These rates for disabling stroke and death for CAS and CEA for those younger than 70 were 2.1 percent versus 2.7 percent compared with 5.7 percent and 2.5 percent for those over the age of 70.

While researchers found that stroke and death were higher in the CAS arm compared to the CEA arm, “the harm of stenting strongly depended on age; whereas estimated risks of stroke or death in patients younger than 70 were similar in the two treatment groups,” the authors wrote.

“Current recommendations have restricted the use of stenting to symptomatic patients with contraindications to endarterectomy, carotid stenosis at surgically inaccessible sites, recurrent stenosis after previous endarterectomy and stenosis after irradiation,” the authors wrote. “Our findings suggest that stenting might also be a viable alternative to endarterectomy in younger patients, in whom surgery could otherwise be undertaken without increased risk.

“In conclusion, there is strong evidence that, in the short term, the harm of stenting compared with endarterectomy decreases with younger age.”