In the latest assessment of the battle between carotid endarterectomy or stenting, the surgical procedure appears to carry less risk of stroke and death, according to a meta-analysis.
Stenting was associated with a 31% increased risk of the periprocedural composite outcome of death, myocardial infarction, or stroke, Deepak L. Bhatt, MD, MPH, of Veterans Affairs Boston Healthcare System, and colleagues reported in the Archives of Neurology.
Yet stented patients had a decreased risk of periprocedural myocardial infarction or cranial nerve palsies, they said.
“Strategies are urgently needed to identify patients who are best served by stenting versus endarterectomy,” they wrote.
There have been several studies to determine the advantages of each procedure, but more recent trials have showed an increased risk of harm with carotid artery stenting. (See Endarterectomy Safer than Carotid Stenting in Symptomatic Patients and Excess Stroke, MI, and Death Seen with Carotid Stenting)
So the researchers conducted a meta-analysis of 13 randomized controlled trials totaling 7,477 patients, who were followed for a mean of 2.7 years.
They found that stenting was associated with an increased risk of the periprocedural composite outcome of death, MI, or stroke (OR 1.31, 95% CI 1.08 to 1.59).
The procedure also was associated with a 65% increased risk of death or stroke, and a 67% increased risk of any stroke, they said.
Yet there was also a 55% reduced risk of myocardial infarction alone, as well as an 85% reduction in cranial nerve injury with stenting, compared with surgery.
In addition to the periprocedural outcomes, which overall favored surgery, the researchers found that the increased risk seen with stenting continues to be seen in the intermediate-to-long-term periods as well.
Yet there is still “an urgent need to develop risk scores to select participants who have a low risk of periprocedural complications following stenting,” they wrote.
And there is also a need for innovation to prevent embolization during carotid stenting, they added.
In an accompanying editorial, Louis Caplan, MD, of Beth Israel Deaconess Medical Center in Boston, and Thomas Brott, MD, of the Mayo Clinic in Jacksonville, Fla., wrote that the take-home message is that “both procedures are effective.”
“Both procedures showed a relatively low rate of serious complications. Surgery is superior concerning some outcomes, stenting seems to have advantages in others.”
They noted that stenting is a newer technology and will have a significant learning curve not seen with endarterectomy, which has been practiced for a longer period of time.
Age also appears to make a difference, they said, because stenting “seems to show better outcomes in younger patients while surgical results have been better in older patients.”
They also noted that another option may be altogether better: “Aggressive medical treatment of blood lipids, blood pressure, and antiplatelets, along with lifestyle changes, may be as good as or better than either surgery or stenting at stroke and MI prevention.”
The editorialists compared the meta-analysis to a horse race in which races run under different circumstances, including weather and track conditions, with different owners and bettors having different stakes in the outcome.
The authors noted limitations of the meta-analysis, including lack of medication data, different outcomes reported in different trials, and absence of enzyme measurements from some trials which could lead to under-reporting of periprocedural myocardial infarction.
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