Carotid Artery Stent Placement and Carotid Endarterectomy: A challenge for Urgent Treatment after Stroke-Early and 12-month outcomes in a Comprehensive Stroke Center
The manuscript presents the results comparing the safety, efficacy and outcomes (short term and 12 month) of patients that presented to a single major stroke center with TIA or Stroke and underwent revascularization within 7 days either with carotid artery stenting (CAS) or carotid endarterectomy (CEA).
Patients were evaluated in the acute phase by a neurologist (not involved in the study) that presented the option of CAS or CEA to the patient or family member after the diagnostic work up had identified the extracranial ICA as the source of the stroke. Revascularization criteria included a carotid lesion on the relevant side with >70% stenosis or unstable plaque with 50-69% stenosis. 110 patients were included, 62 underwent CAS and 48 CEA.
Clinical outcomes evaluated included: type of event, stroke severity, disability (evaluated at 6 time points), periprocedural and postprocedural complications. Outcome measures evaluated new onset of stroke or vascular death, neurologic worsening, brain or systemic hemorrhagic complications, functional outcome, lesion restenosis, cardiac events, cognitive symptoms, and nerve lesions.
The authors found that CAS patients had more instances of CAD and intracranial stenosis, higher ESR, had a higher number of major stroke and were treated later when compared to the CEA group.
Incidences of all complications were similar between both groups. The severity of the event showed significant treatment effect that was related to the lower severity in CEA patients. Functional improvement, survival, stroke and vascular death at 12 months were all similar between both groups.
The need for early revascularization has been documented by the decreased risk of stroke or death (6% in treated patients vs. 18.8% in non-treated patients). The authors highlight that the patients included here are representative of the population that is being evaluated in emergency departments (high proportion of stroke vs TIA). The authors point out that even though stroke severity was higher at admission and at 1 month in the CAS group, functional changes were similar to CEA patients. While the 12 month survival was similar, worse outcomes were observed in the CAS group, which could be the result of confounding factors and not the CAS procedure.
The study has some limitations: small sample size, retrospective nature and the lack of standardization of the CEA procedure. In addition, newer techniques such as Transcarotid artery revascularization with flow reversal, might influence the safety of CAS particularly in patients with plaque in the aorta and aortic arch.
The authors mention that confounding factors might have been minimized since the patients were all evaluated at a single stroke center with experienced surgeons and interventionalists.
The authors conclude that CAS proved to be equivalent to CEA in the early revascularization of patients with TIA or acute ischemic stroke (including severe stroke).
Figure- NIHSS scores across time in both CEA and CAS patients. Significant treatment effect was driven by the lower severity in CEA patients. Both groups showed improvement over time.
This retrospective study makes a compelling argument that CAS should be considered at least equivalent to CEA in the early revascularization of patients that have suffered a TIA or stroke. While historically CEA has been considered superior, newer techniques and more technical experience have made CAS safer and more effective than the results of previous studies. This study included patients with more severe stroke (when compared to prior published studies), and found that CAS and CEA had similar survival, functional outcome, secondary stroke prevention and complication results, despite the CAS group presenting with higher severity scores and more comorbidities. This study evaluated a consecutive group of patients that closely resemble patients that present at stroke centers, and found that in the hands of experienced surgeons and IRs, the complication rates and clinical outcomes are similar. Modern techniques and more extensive experience might prove to make CAS equivalent in this patient population, and further studies are needed to validate the promising results presented in this manuscript.
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Rocco A, Sallustio F, Toschi N, Rizzato B, Legramante J, Ippoliti A, Marchetti AA, Pampana E, Gandini R, Diomedi M. Carotid Artery Stent Placement and Carotid Endarterectomy: A Challenge for Urgent Treatment after Stroke-Early and 12-Month Outcomes in a Comprehensive Stroke Center. J Vasc Interv Radiol. 2018 Sep;29(9):1254-1261.e2. doi: 10.1016/j.jvir.2018.03.025. Epub 2018 Jun 21. PubMed PMID: 29935838.
Carlos J. Guevara, MD
Department of Radiology, Interventional Radiology Division
University of Texas Health Sciences, Houston