Letter by Moris and Avgerinos Regarding Article, “Long-Term Outcome After Carotid Artery Stenting: A Population-Based Matched Cohort Study”
To the Editor:
We read with great interest the recent publication of Jonsson et al1 assessing the long-term outcomes after carotid stenting (CAS) compared with carotid endarterectomy (CEA), in terms of stroke and death. The main finding of the study was that CAS was associated with an increased long-term risk of ipsilateral stroke and death during the perioperative phase when compared with CEA. These results were recently confirmed by a systematic review that demonstrated that stroke/death rates after CAS remain significantly higher than that after CEA in both symptomatic and asymptomatic patients.2
On the contrary, the long-term results of the CREST (Carotid Revascularization Endarterectomy Versus Stenting Trial)3 showed a rate of the primary long-term end point (postprocedural ipsilateral stroke over the 10-year follow-up) that did not differ significantly between the CAS and CEA group (hazard ratio, 0.99; 95% confidence interval, 0.64–1.52). However, CREST included both symptomatic and asymptomatic patients with almost 1:1 ratio (1180 asymptomatic and 1322 symptomatic). That was not the case in the Swedish study,1 where asymptomatic patients were only ≈31.7% (364 cases) of the patients enrolled (P<0.0001 compared with CREST). This difference may affect the final results of the study because a recent trial4 that evaluated the efficacy of CAS in asymptomatic patients with severe stenosis and low or moderate morbidity risk demonstrated that CAS was not inferior to CEA in terms of stroke and death within the first 30 days after intervention (3.3% versus 2.6%; P=0.6). Similarly, at 5-year follow-up, the survival rate for the CAS group was 87.1% and 89.4% for the CEA group (P=0.21), and the rate of freedom from nonprocedure-related ipsilateral stroke was 97.8% and 97.3%, respectively (P=0.51).4
The outcomes of CEA under regional anesthesia is another issue that deserves to be explored. The authors did not mention the percentage of CEA group for which regional anesthesia was applied. Another analysis of the CREST data5 comparing CAS versus CEA under general anesthesia versus CEA under regional anesthesia in both symptomatic and asymptomatic patients demonstrated a noninferiority of CAS compared with CEA under regional anesthesia in terms of terms of stroke or death (odds ratio, 0.20; 95% confidence interval, 0.03–1.47; P=0.11) and inferiority compared with CEA under general anesthesia (odds ratio, 0.46; 95% confidence interval, 0.27–0.76; P=0.003). So, it would be of interest if the authors provided a CEA subgroup analysis that would facilitate the deeper understanding of the presented results.
Finally, this study1 also omitted to address the controversial and debatable question about the optimal management of patients with asymptomatic or symptomatic carotid stenosis. Similar to CREST3 that included both symptomatic and asymptomatic patients and did not compare CAS versus CEA versus best medical treatment for asymptomatic patients, the Swedish study1 also did not shed light to the real issue, which is the comparison of CAS versus CEA versus best medical treatment.
Thus, the need to launch well-designed trials, addressing all these issues, is compulsory.
Demetrios Moris, MD, PhD
Lerner Research Institute
Cleveland Clinic Foundation
Efthymios Avgerinos, MD, PhD
Division of Vascular Surgery
University of Pittsburgh Medical Center
- © 2016 American Heart Association, Inc.
- Jonsson M,
- Lindström D,
- Gillgren P,
- Wanhainen A,
- Malmstedt J
- Moris D,
- Bakoyiannis C,
- Kakkos S