Long-Term Outcomes May Still Favor Carotid Endarterectomy in Carotid Stenosis

carotid angiogram
carotid angiogram
A pooled analysis of patient data analyzed the safety and efficacy of stenting and endarterectomy for symptomatic carotid stenosis.

In the postprocedural period, carotid artery stenting (CAS) and carotid endarterectomy (CEA) were similarly effective in treating patients with carotid stenosis. CEA, however, may have more favorable long-term outcomes when combining postprocedural and periprocedural risk, according to a study published in Lancet Neurology.

The investigators of this study sought to compare long-term outcomes of CAS and CEA for treating symptomatic carotid stenosis using pooled individual patient-level data from 4 major randomized controlled trials.

The study sample included a total of 4754 patients who participated in 4 large multicenter, randomized controlled trials (EVA-3S, SPACE, ICSS, and CREST) assessing the effectiveness of CAS and CEA for the treatment of recent symptomatic carotid stenosis.

Participants were analyzed for postprocedural risk of ipsilateral stroke or death defined as between 121 days and 1, 3, 5, 7, 9, and 10 years after randomization.

Primary outcomes included the composite risk of stroke or death from the periprocedural period (within 120 days after randomization) through the postprocedural period (up to 10 years after randomization) and the treatment differences between the defined time points above. The risk was calculated using Kaplan-Meier methods and hazard rates were estimated using a Cox proportional model and adjusted for differences between the contributing trials.  

In patients undergoing CEA, 129 periprocedural outcome events and 55 postprocedural events were observed; in patients receiving CAS, 206 periprocedural and 57 postprocedural events were observed.

The annual rate of ipsilateral stroke during the postprocedural period was similar for the 2 treatments, in which 0.6% of endarterectomy patients (95% CI, 0.46-0.79) and 0.64% of stenting patients (95% CI, 0.49-0.83) reported outcome events.

However, long-term outcomes (combining periprocedural and postprocedural risk) still showed hazard rates for endarterectomy that were lower than those for stenting with a treatment difference ranging between 2.8% to 4.1% at 1-, 3-, 5-, 7-, and 9-year follow-up periods.

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Limitations to the study included variability in surgical training and experience and differences in the intensity of patient examination during follow-up. Furthermore, the trials were limited to first strokes and did not provide information on the risk of recurrent stroke.

Postprocedural outcomes were similar for CEA and CAS, however, the combined long-term outcomes favored endarterectomy. The investigators suggest that these results support improving the periprocedural safety of CAS, including the patient selection process and stenting techniques.


Brott TG, Calvet D, Howard G, et al. Long-term outcomes of stenting and endarterectomy for symptomatic carotid stenosis: a preplanned pooled analysis of individual patient data [published online February 6, 2019]. Lancet Neurol. doi: 10.1016/S1474-4422(19)30028-6