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Stents, Surgery Equal For Blocked Carotids

Thu, 02/20/2014 - 11:04am
Todd Neale

For patients with symptomatic or asymptomatic carotid artery stenosis, stenting and endarterectomy appear to be equally effective for preventing ipsilateral stroke over the long term, a small, single-center trial suggested.

But, though there was no difference in that outcome, the rate of fatal and nonfatal myocardial infarction (MI) through 10 to 13 years of follow-up was higher in patients who underwent endarterectomy (HR 2.27, 95% CI 1.35-3.82), according to William Brooks, MD, of Baptist Health Lexington in Kentucky, and colleagues.

The risk of MI also was higher in patients with symptomatic disease than it was in those without symptoms, regardless of revascularization procedure (27.5% versus 11%; HR 2.32, 95% CI 1.30 to 4.15), the researchers reported in the February issue of JACC: Cardiovascular Interventions.

"The collective data from this long-term trial clearly suggest that [stenting and surgery] are equally effective in long-term prevention of ipsilateral ischemic stroke," they wrote. "Furthermore, these observations suggest [stenting] may be superior in the context of overall, long-term event-free survival."

Taken together, this and other trials indicate that stenting and surgery "have reached clinical equipoise as strategies for carotid revascularization," according to Robert Safian, MD, of Beaumont Health System in Royal Oak, Mich.

But, "although proponents of carotid angioplasty and stenting may cheer this study, I find it somewhat enigmatic in some respects and compelling in others," he wrote in an accompanying editorial.

He pointed to the lack of any periprocedural strokes, which contrasted with prior trials showing rates of 2.3 percent to 7.9 percent with stenting and surgery. Also, there was an "exceedingly high" mortality rate (50.2%) through long-term follow-up and a separation of the MI rates between the two groups beyond 5 years, findings that support the need for longer-term follow-up in trials of carotid revascularization, Safian said.

Now, he said, there is a need to study the use of optimal medical therapies for carotid artery disease.

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