News Release

Stenting should be avoided in patients over 70 for treatment for symptomatic blockage of neck arteries (carotid stenosis), but both stenting and endarterectomy are safe in younger patients

Peer-Reviewed Publication

The Lancet_DELETED

Results from previous studies have shown that, in patients being treated for symptomatic blockage of their neck arteries (carotid stenosis), stenting is associated with higher short-term risk of stroke than surgical widening of the artery (endarterectomy). But a new meta-analysis shows that, while stenting should be avoided in patients aged 70 years of over, it could be as safe as endarterectomy in younger patients. The Article, published Online First in The Lancet, is by the Carotid Stenting Trialists Collaboration, which was set up by Professor Martin M Brown, National Hospital for Neurology and Neurosurgery and the Institute of Neurology, University College London, UK, with colleagues involved in the major carotid stenting trials.

People whose neck arteries are partially blocked by fatty deposits can experience symptoms including transient ischaemic attacks ("mini-strokes") and minor or major strokes. This is because blood clots formed on the fatty deposits blocking the artery can break off and obstruct blood flow in the brain. But despite the earlier results discussed above, Brown and colleagues believed these previous studies were not of sufficient size to establish relative safety of stenting versus endarterectomy in specific patient subgroups.

The researchers used data from all 3433 patients with symptomatic carotid stenosis from three trials, the EVA-3S , SPACE, and ICSS studies, in their analysis. The primary outcome event was any stroke or death.

In the first 120 days after randomisation, any stroke or death was 53% more likely to occur in the stenting group than in the carotid endarterectomy group (153 [8•9%] of 1725 allocated stenting; 99 [5•8%] of 1708 allocated endarterectomy). Of all subgroup variables assessed*, only age significantly modified the treatment effect: in patients younger than 70 years, the estimated 120-day risk of stroke or death was similar in both groups (50 [5•8%] of 869 patients allocated stenting; 48 [5∙7%] of 843 allocated endarterectomy). But in patients 70 years or older, the estimated risk with carotid stenting was twice that with carotid endarterectomy (103 [12∙0%] of 856 vs 51 [5∙9%] of 865.

Risk estimates of stroke or death within 30 days of treatment among patients younger than 70 years were similar for both groups (5•1% after stenting vs 4•5% after endarterectomy); in patients 70 years or older, the estimates were 10∙5% after stenting vs 4.4% after endarterectomy.

The authors conclude: "The harm of stenting strongly depended on age; whereas estimated risks of stroke or death in patients younger than 70 years were similar in the two treatment groups, we noted that the risk of stenting doubled among patients 70 years or older compared with the younger age group. By contrast, the risk of stroke or death associated with endarterectomy was similar in old and young patients…in conclusion, there is strong evidence that, in the short term, the harm of stenting compared with endarterectomy decreases with younger age."

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Professor Martin M Brown, National Hospital for Neurology and Neurosurgery and Institute of Neurology, University College London, UK. T) +44 (0) 20 7829 8753 Email: m.brown@ion.ucl.ac.uk

For full Article, see: http://press.thelancet.com/carotid.pdf

Note to editors: Other variables assessed were sex, history of diabetes, history of hypertension, systolic blood pressure at randomisation, history of hypercholesterolaemia, smoking history, history of coronary heart disease, history of peripheral artery disease, type of most recent symptoms, past history of stroke, degree of treated carotid stenosis, whether treatment occurred within 14 days of most recent event, number of patients recruited per centre, and centre recruitment rate.

A linked Comment is not ready at this time but will be published when the Article appears in an upcoming edition of The Lancet.

Note from Prof Brown: The authors discussed their findings in the context of the recently-published trial, CREST, which was not included in the pooled analysis. However, when the short-term rates of stroke and death of all the carotid stenting versus endarterectomy trials, including CREST, were analysed together in a web appendix, the results for patients with recently symptomatic carotid stenosis were very similar to the results of the pooled analysis, strongly favouring carotid endarterectomy. The authors noted that in contrast the rates of myocardial infarction in CREST were higher in both groups (2.5% after endarterectomy and 1.0% after stenting) than in the pooled analysis of EVA-3S, SPACE and ICSS (less than 0.5% in both groups). This difference was attributed to the fact that CREST screened all patients for rises in cardiac enzymes, whether or not they had symptoms, whereas the other trials mainly only tested patients with symptoms. CREST also recruited more patients with heart disease, which may have contributed to the higher rates of myocardial infarction. The authors of the pooled analysis concluded in relation to these findings that any excess of silent myocardial infarction after endarterectomy is likely to be counterbalanced by an excess of silent brain infarction after stenting, which was shown in a previous published substudy from ICSS.

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