Expedited carotid artery surgery after index event “probably safer” than expedited stenting

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A systematic review and meta-analysis of 71 studies suggests that, at present, carotid endarterectomy (CEA) is safer than carotid artery stenting (CAS) when performed within two or seven days of the index event. “The findings of this analysis will guide clinical practice when deciding on the type of intervention in the symptomatic patient with severe carotid stenosis,” authors Andreia Coelho (Centro Hospitalar Universitário de Porto, Porto, Portgual) and colleagues write in the European Journal of Vascular and Endovascular Surgery (EJVES), where the findings were published as an Editor’s choice paper. Coelho et al stress that the ideal timing of performing CAS in symptomatic patients, when indicated against CEA, is not yet defined.

European Society for Vascular Surgery (ESVS) guidelines advise that CEA or CAS should be performed within 14 days of symptom onset, the authors communicate. However, they note that the evidence would suggest there has been a drive towards performing interventions well within 14 days, especially in Europe. In addition, they write that a temporal trend towards a progressive decrease in delays from index event to undergoing CEA or CAS has been reported in several national registries. However, mixed findings about the impact of intervening within 48 hours of index event have been reported, Coelho et al stress.

In order to analyse the timing of carotid interventions after index event, as well as 30-day outcomes at varying time periods within 14 days of symptom onset, the investigators initiated a systematic review and meta-analysis of the available data.

Coelho and colleagues first performed a systematic review, involving an online search of the Medline and Cochrane databases. Endpoints included procedural stroke and/or death stratified by delay from the index event and surgical technique, they convey.

The investigators included 71 studies with 232,952 symptomatic patients. They detail that the 71 studies comprised of 34 retrospective databases, nine prospective, three randomised controlled trials, three case-control, and 22 retrospective studies.

Writing in EJVES, Coelho et al report that CAS was associated with higher 30-day stroke (odds ratio [OR], 0.7; 95% confidence interval [CI], 0.58–0.85) and mortality rates (OR, 0.41; 95% CI, 0.31–0.53) compared with CEA when performed within two days of symptom onset.

The research team analysed patients undergoing CEA/CAS in different time frames: ≤2 vs. 3–14 and ≤7 vs. 8–14 days, which revealed that expedited CEA (vs. 3–14 days) presented a sampled 30-day stroke rate of 1.4%; 95% CI, 0.9–1.8 vs. 1.8%; 95% CI, 1.8–2, with no statistically significant difference. Expedited CAS (vs. 3–14 days), they note, was associated with no difference in stroke rate but statistically significantly higher mortality rate (OR, 2.76; 95% CI, 1.39–5.5).

In the discussion of their findings, Coelho and colleagues write that there were inconsistent findings regarding timing and outcomes in CAS patients. They elaborate: “In patients undergoing CAS ≤2 days of the index event (vs. 3–14), there was no apparent different in 30-day stroke or MI [myocardial infarction] but there was a statistically significantly higher risk of death. Conversely, there were no differences in 30-day outcomes between CAS performed ≤7 days (vs. 8–14).” The authors hypothesise that the pathophysiology of procedural stroke may differ with expedited, versus delayed, interventions in line with acute changes in atherosclerotic plaque vulnerability, which have been associated with an increased risk of embolism and neurological events after CAS.

The investigators also address some limitations of the studies included in their analysis, including that fact that the studies analysed are of moderate to low quality. In addition, they state that “probably one of the main biases” in the study was introduced in the election for CAS/CEA, with fit patients treated by CEA while high-risk patients were treated by CAS.

The data suggest that, at the current time, CEA is “probably safer” than CAS when performed within two or seven days after symptom onset, the authors conclude. Considering the wider topic area, they add that no studies have published outcome data for transcarotid artery revascularisation (TCAR) when used in the first 14 days after symptom onset as of yet, and that these data are “keenly awaited”.


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