Ten-Year Stroke Risk Is Comparable After Carotid Stenting or Endarterectomy

Summary and Comment |
March 11, 2016

Ten-Year Stroke Risk Is Comparable After Carotid Stenting or Endarterectomy

  1. Anthony S. Kim, MD, MAS

Both procedures appear to be durable over the long term, and ipsilateral stroke was uncommon in both groups.

  1. Anthony S. Kim, MD, MAS

The CREST (Carotid Revascularization Endarterectomy versus Stenting Trial) investigators previously reported no significant difference in the incidence of the primary composite outcome at 4 years (stroke, myocardial infarction, or death during the periprocedural period or subsequent ipsilateral stroke for endarterectomy compared with stenting). However, during the periprocedural period, there were more strokes with stenting and more myocardial infarctions with endarterectomy.

Although the reported incidence of ipsilateral stroke was similar for the two groups in CREST (2.0% for stenting, 2.4% for endarterectomy), lingering concerns about the long-term durability of these procedures combined with the long life expectancy of many of the CREST participants prompted the original CREST sponsors (NINDS and Abbott Vascular Solutions) to extend the follow-up period to 10 years. A total of 1607 of the original 2502 CREST participants consented to extended follow-up. Approximately half had asymptomatic carotid-artery stenosis, and those who consented to extended follow-up were more likely than nonconsenters to have asymptomatic carotid-artery stenosis or dyslipidemia and less likely to have diabetes or to smoke.

At 10 years, investigators found no significant difference in the incidence of the primary composite outcome (11.8% with stenting, 9.9% with endarterectomy) or in the estimated risk for subsequent ipsilateral stroke in particular (6.9% vs. 5.6%).

Comment

These data should help to dispel lingering concerns about the long-term durability of carotid revascularization procedures, but the stroke rate over the long term for both arms was much lower than reported in studies from just a couple of decades ago. This low long-term stroke risk reemphasizes the importance of reducing periprocedural risks up front, especially for stenting, and particularly if CREST's rigorous credentialing process selected for proceduralists with better outcomes. Left unresolved is whether either intervention is justified for asymptomatic carotid-artery stenosis given improvements in medical management — a question that the ongoing Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial (CREST-2) is designed to address.

Dr. Kim is Assistant Professor, Department of Neurology, University of California, San Francisco.

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