Vascular surgery appears to be safer than stenting for patients over 70 years of age with carotid stenosis, or a blockage of the carotid arteries in the neck, according to new findings published today in the Lancet.
The international study, led by investigators at the University of Alabama at Birmingham, looked at the two standard methods for treating plaque buildup in the carotid arteries: a surgical procedure called carotid endarterectomy against carotid artery stenting.
The surgical procedure, or CEA, involves surgeons’ opening up the artery to remove plaque. It is an invasive surgery first done in 1946. Stenting is a newer, less invasive procedure in which a catheter is threaded through blood vessels, usually from the groin, to the affected area in the artery. A balloon is used to open the blocked artery, and a mesh stent is placed to hold it open.
“Stenting was hailed as a less invasive alternative to surgery, one that avoided many of the hazards and risks inherent in a surgical procedure,” said George Howard, Dr.P.H., professor in the Department of Biostatistics in the UAB School of Public Health and the study’s first author. “What we find, however, is that the risk of stroke in patients over the age of 70 is twice that with stenting than with the surgical CEA procedure.”
The study looked at data from four randomized controlled trials within the Carotid Stenosis Trialists’ Collaboration with patients with symptomatic carotid stenosis. Collectively, 4,754 patients were followed. Age was not associated with increased stroke risk for either surgery or stenting in patients under age 70; but stent patients over 70 had an increased risk, particularly in the immediate time frame of the procedure.
“These findings are very conclusive — stenting has a higher risk for stroke over carotid surgery in the older patient, older than 70,” Howard said. “This study should help drive decision-making and establish appropriate practice guidelines in the treatment of carotid stenosis.”
Howard says the stenting procedure itself seems to be causing the increased risk.
“The risk appears centered on the periprocedural period, the time during and immediately after the procedure,” Howard said. “The risk does not appear to continue in the months or years following the procedure.”
Howard acknowledges that advances in stenting, such as the routine use of closed-cell stents, which seem to be associated with lower rates of procedural stroke and the development of novel protection systems, might allow safe stenting for elderly people in the future.
“But for now, stenting in an older population needs to be done with great caution,” he said.
About this stroke research
In addition to investigators at UAB, the international study included investigators from Cardiovascular Associates of the Southeast, Birmingham, Alabama; Clinic for Radiology and Neuroradiology, UKSH Campus Kiel, Kiel, Germany; Department of Radiology, University Medical Center Utrecht, Utrecht, Netherlands; Nuffield Department of Surgical Sciences, John Radcliffe Hospital, Oxford, U.K.; Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria; Department of Vascular and Endovascular Surgery, Vascular Center, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany; Department of Neurology, Hôpital Sainte-Anne, Université Paris-Descartes, DHU Neurovasc Sorbonne Paris Cité, INSERM U894, Paris, France; Clinical Trial Service Unit and Epidemiological Studies Unit, Oxford University, Oxford, U.K.; Department of Neurology and Stroke Center, University Hospital Basel, Basel, Switzerland; Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, London, U.K.; and Department of Vascular Surgery, University of Paris, XII, Hôpital Henri Mondor, Paris.
Source: Bob Shepard – University of Birmingham Alabama Image Source: The image is in the public domain. Original Research:Abstract for “Association between age and risk of stroke or death from carotid endarterectomy and carotid stenting: a meta-analysis of pooled patient data from four randomised trials” by Prof George Howard, DrPH, Prof Gary S Roubin, MD, Prof Olav Jansen, MD, Prof Jeroen Hendrikse, MD, Prof Alison Halliday, MD, Prof Gustav Fraedrich, MD, Prof Hans-Henning Eckstein, MD, David Calvet, MD, Richard Bulbulia, MD, Leo H Bonati, MD, Prof Jean-Pierre Becquemin, MD, Prof Ale Algra, MD, Prof Martin M Brown, MD, Prof Peter A Ringleb, MD, Prof Thomas G Brott, MD, and Prof Jean-Louis Mas, MD on behalf of the Carotid Stenting Trialists’ Collaboration in The Lancet. Published online February 12 2016 doi:10.1016/S0140-6736(15)01309-4
Association between age and risk of stroke or death from carotid endarterectomy and carotid stenting: a meta-analysis of pooled patient data from four randomised trials
Background Age was reported to be an effect-modifier in four randomised controlled trials comparing carotid artery stenting (CAS) and carotid endarterectomy (CEA), with better CEA outcomes than CAS outcomes noted in the more elderly patients. We aimed to describe the association of age with treatment differences in symptomatic patients and provide age-specific estimates of the risk of stroke and death within narrow (5 year) age groups.
Methods In this meta-analysis, we analysed individual patient-level data from four randomised controlled trials within the Carotid Stenosis Trialists’ Collaboration (CSTC) involving patients with symptomatic carotid stenosis. We included only trials that randomly assigned patients to CAS or CEA and only patients with symptomatic stenosis. We assessed rates of stroke or death in 5-year age groups in the periprocedural period (between randomisation and 120 days) and ipsilateral stroke during long-term follow-up for patients assigned to CAS or CEA. We also assessed differences between CAS and CEA. All analyses were done on an intention-to-treat basis.
Findings Collectively, 4754 patients were randomly assigned to either CEA or CAS treatment in the four studies. 433 events occurred over a median follow-up of 2·7 years. For patients assigned to CAS, the periprocedural hazard ratio (HR) for stroke and death in patients aged 65–69 years compared with patients younger than 60 years was 2·16 (95% CI 1·13–4·13), with HRs of roughly 4·0 for patients aged 70 years or older. We noted no evidence of an increased periprocedural risk by age group in the CEA group (p=0·34). These changes underpinned a CAS-versus CEA periprocedural HR of 1·61 (95% CI 0·90–2·88) for patients aged 65–69 years and an HR of 2·09 (1·32–3·32) for patients aged 70–74 years. Age was not associated with the postprocedural stroke risk either within treatment group (p≥0·09 for CAS and 0·83 for CEA), or between treatment groups (p=0·84).
Interpretation In these RCTs, CAS was clearly superior to CEA in patients aged 70–74 years and older. The difference in older patients was almost wholly attributable to increasing periprocedural stroke risk in patients treated with CAS. Age had little effect on CEA periprocedural risk or on postprocedural risk after either procedure.
“Association between age and risk of stroke or death from carotid endarterectomy and carotid stenting: a meta-analysis of pooled patient data from four randomised trials” by Prof George Howard, DrPH, Prof Gary S Roubin, MD, Prof Olav Jansen, MD, Prof Jeroen Hendrikse, MD, Prof Alison Halliday, MD, Prof Gustav Fraedrich, MD, Prof Hans-Henning Eckstein, MD, David Calvet, MD, Richard Bulbulia, MD, Leo H Bonati, MD, Prof Jean-Pierre Becquemin, MD, Prof Ale Algra, MD, Prof Martin M Brown, MD, Prof Peter A Ringleb, MD, Prof Thomas G Brott, MD, and Prof Jean-Louis Mas, MD on behalf of the Carotid Stenting Trialists’ Collaboration in The Lancet. Published online February 12 2016 doi:10.1016/S0140-6736(15)01309-4