Early Endarterectomy Carries a Lower Procedural Risk Than Early Stenting in Patients with Symptomatic Stenosis of the Internal Carotid Artery

Results from 4 Randomized Controlled Trials

Barbara Rantner, Barbara Kollerits, Gary S. Roubin, Peter A. Ringleb, Olaf Jansen, George Howard, Jeroen Hendrikse, Alison Halliday, John Gregson, Hans Henning Eckstein, David Calvet, Richard Bulbulia, Leo H. Bonati, Jean Pierre Becquemin, Ale Algra, Martin M. Brown, Jean Louis Mas, Thomas G Brott, Gustav Fraedrich

Research output: Contribution to journalArticle

27 Citations (Scopus)

Abstract

Background and Purpose-Patients undergoing carotid endarterectomy (CEA) for symptomatic stenosis of the internal carotid artery benefit from early intervention. Heterogeneous data are available on the influence of timing of carotid artery stenting (CAS) on procedural risk. Methods-We investigated the association between timing of treatment (0-7 days and >7 days after the qualifying neurological event) and the 30-day risk of stroke or death after CAS or CEA in a pooled analysis of individual patient data from 4 randomized trials by the Carotid Stenosis Trialists' Collaboration. Analyses were done per protocol. To obtain combined estimates, logistic mixed models were applied. Results-Among a total of 4138 patients, a minority received their allocated treatment within 7 days after symptom onset (14% CAS versus 11% CEA). Among patients treated within 1 week of symptoms, those treated by CAS had a higher risk of stroke or death compared with those treated with CEA: 8.3% versus 1.3%, risk ratio, 6.7; 95% confidence interval, 2.1 to 21.9 (adjusted for age at treatment, sex, and type of qualifying event). For interventions after 1 week, CAS was also more hazardous than CEA: 7.1% versus 3.6%, adjusted risk ratio, 2.0; 95% confidence interval, 1.5 to 2.7 (P value for interaction with time interval 0.06). Conclusions-In randomized trials comparing stenting with CEA for symptomatic carotid artery stenosis, CAS was associated with a substantially higher periprocedural risk during the first 7 days after the onset of symptoms. Early surgery is safer than stenting for preventing future stroke. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT00190398; URL: http://www.controlled-Trials.com. Unique identifier: ISRCTN57874028; Unique identifier: ISRCTN25337470; URL: http://www.clinicaltrials.gov. Unique identifier: NCT00004732.

Original languageEnglish (US)
Pages (from-to)1580-1587
Number of pages8
JournalStroke
Volume48
Issue number6
DOIs
StatePublished - Jun 1 2017

Fingerprint

Endarterectomy
Carotid Endarterectomy
Carotid Stenosis
Carotid Arteries
Randomized Controlled Trials
Stroke
Odds Ratio
Confidence Intervals
Therapeutics
Logistic Models
Clinical Trials

Keywords

  • carotid
  • carotid artery
  • carotid artery diseases
  • endarterectomy
  • stent
  • stroke

ASJC Scopus subject areas

  • Clinical Neurology
  • Cardiology and Cardiovascular Medicine
  • Advanced and Specialized Nursing

Cite this

Early Endarterectomy Carries a Lower Procedural Risk Than Early Stenting in Patients with Symptomatic Stenosis of the Internal Carotid Artery : Results from 4 Randomized Controlled Trials. / Rantner, Barbara; Kollerits, Barbara; Roubin, Gary S.; Ringleb, Peter A.; Jansen, Olaf; Howard, George; Hendrikse, Jeroen; Halliday, Alison; Gregson, John; Eckstein, Hans Henning; Calvet, David; Bulbulia, Richard; Bonati, Leo H.; Becquemin, Jean Pierre; Algra, Ale; Brown, Martin M.; Mas, Jean Louis; Brott, Thomas G; Fraedrich, Gustav.

In: Stroke, Vol. 48, No. 6, 01.06.2017, p. 1580-1587.

Research output: Contribution to journalArticle

Rantner, B, Kollerits, B, Roubin, GS, Ringleb, PA, Jansen, O, Howard, G, Hendrikse, J, Halliday, A, Gregson, J, Eckstein, HH, Calvet, D, Bulbulia, R, Bonati, LH, Becquemin, JP, Algra, A, Brown, MM, Mas, JL, Brott, TG & Fraedrich, G 2017, 'Early Endarterectomy Carries a Lower Procedural Risk Than Early Stenting in Patients with Symptomatic Stenosis of the Internal Carotid Artery: Results from 4 Randomized Controlled Trials', Stroke, vol. 48, no. 6, pp. 1580-1587. https://doi.org/10.1161/STROKEAHA.116.016233
Rantner, Barbara ; Kollerits, Barbara ; Roubin, Gary S. ; Ringleb, Peter A. ; Jansen, Olaf ; Howard, George ; Hendrikse, Jeroen ; Halliday, Alison ; Gregson, John ; Eckstein, Hans Henning ; Calvet, David ; Bulbulia, Richard ; Bonati, Leo H. ; Becquemin, Jean Pierre ; Algra, Ale ; Brown, Martin M. ; Mas, Jean Louis ; Brott, Thomas G ; Fraedrich, Gustav. / Early Endarterectomy Carries a Lower Procedural Risk Than Early Stenting in Patients with Symptomatic Stenosis of the Internal Carotid Artery : Results from 4 Randomized Controlled Trials. In: Stroke. 2017 ; Vol. 48, No. 6. pp. 1580-1587.
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abstract = "Background and Purpose-Patients undergoing carotid endarterectomy (CEA) for symptomatic stenosis of the internal carotid artery benefit from early intervention. Heterogeneous data are available on the influence of timing of carotid artery stenting (CAS) on procedural risk. Methods-We investigated the association between timing of treatment (0-7 days and >7 days after the qualifying neurological event) and the 30-day risk of stroke or death after CAS or CEA in a pooled analysis of individual patient data from 4 randomized trials by the Carotid Stenosis Trialists' Collaboration. Analyses were done per protocol. To obtain combined estimates, logistic mixed models were applied. Results-Among a total of 4138 patients, a minority received their allocated treatment within 7 days after symptom onset (14{\%} CAS versus 11{\%} CEA). Among patients treated within 1 week of symptoms, those treated by CAS had a higher risk of stroke or death compared with those treated with CEA: 8.3{\%} versus 1.3{\%}, risk ratio, 6.7; 95{\%} confidence interval, 2.1 to 21.9 (adjusted for age at treatment, sex, and type of qualifying event). For interventions after 1 week, CAS was also more hazardous than CEA: 7.1{\%} versus 3.6{\%}, adjusted risk ratio, 2.0; 95{\%} confidence interval, 1.5 to 2.7 (P value for interaction with time interval 0.06). Conclusions-In randomized trials comparing stenting with CEA for symptomatic carotid artery stenosis, CAS was associated with a substantially higher periprocedural risk during the first 7 days after the onset of symptoms. Early surgery is safer than stenting for preventing future stroke. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT00190398; URL: http://www.controlled-Trials.com. Unique identifier: ISRCTN57874028; Unique identifier: ISRCTN25337470; URL: http://www.clinicaltrials.gov. Unique identifier: NCT00004732.",
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T2 - Results from 4 Randomized Controlled Trials

AU - Rantner, Barbara

AU - Kollerits, Barbara

AU - Roubin, Gary S.

AU - Ringleb, Peter A.

AU - Jansen, Olaf

AU - Howard, George

AU - Hendrikse, Jeroen

AU - Halliday, Alison

AU - Gregson, John

AU - Eckstein, Hans Henning

AU - Calvet, David

AU - Bulbulia, Richard

AU - Bonati, Leo H.

AU - Becquemin, Jean Pierre

AU - Algra, Ale

AU - Brown, Martin M.

AU - Mas, Jean Louis

AU - Brott, Thomas G

AU - Fraedrich, Gustav

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N2 - Background and Purpose-Patients undergoing carotid endarterectomy (CEA) for symptomatic stenosis of the internal carotid artery benefit from early intervention. Heterogeneous data are available on the influence of timing of carotid artery stenting (CAS) on procedural risk. Methods-We investigated the association between timing of treatment (0-7 days and >7 days after the qualifying neurological event) and the 30-day risk of stroke or death after CAS or CEA in a pooled analysis of individual patient data from 4 randomized trials by the Carotid Stenosis Trialists' Collaboration. Analyses were done per protocol. To obtain combined estimates, logistic mixed models were applied. Results-Among a total of 4138 patients, a minority received their allocated treatment within 7 days after symptom onset (14% CAS versus 11% CEA). Among patients treated within 1 week of symptoms, those treated by CAS had a higher risk of stroke or death compared with those treated with CEA: 8.3% versus 1.3%, risk ratio, 6.7; 95% confidence interval, 2.1 to 21.9 (adjusted for age at treatment, sex, and type of qualifying event). For interventions after 1 week, CAS was also more hazardous than CEA: 7.1% versus 3.6%, adjusted risk ratio, 2.0; 95% confidence interval, 1.5 to 2.7 (P value for interaction with time interval 0.06). Conclusions-In randomized trials comparing stenting with CEA for symptomatic carotid artery stenosis, CAS was associated with a substantially higher periprocedural risk during the first 7 days after the onset of symptoms. Early surgery is safer than stenting for preventing future stroke. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT00190398; URL: http://www.controlled-Trials.com. Unique identifier: ISRCTN57874028; Unique identifier: ISRCTN25337470; URL: http://www.clinicaltrials.gov. Unique identifier: NCT00004732.

AB - Background and Purpose-Patients undergoing carotid endarterectomy (CEA) for symptomatic stenosis of the internal carotid artery benefit from early intervention. Heterogeneous data are available on the influence of timing of carotid artery stenting (CAS) on procedural risk. Methods-We investigated the association between timing of treatment (0-7 days and >7 days after the qualifying neurological event) and the 30-day risk of stroke or death after CAS or CEA in a pooled analysis of individual patient data from 4 randomized trials by the Carotid Stenosis Trialists' Collaboration. Analyses were done per protocol. To obtain combined estimates, logistic mixed models were applied. Results-Among a total of 4138 patients, a minority received their allocated treatment within 7 days after symptom onset (14% CAS versus 11% CEA). Among patients treated within 1 week of symptoms, those treated by CAS had a higher risk of stroke or death compared with those treated with CEA: 8.3% versus 1.3%, risk ratio, 6.7; 95% confidence interval, 2.1 to 21.9 (adjusted for age at treatment, sex, and type of qualifying event). For interventions after 1 week, CAS was also more hazardous than CEA: 7.1% versus 3.6%, adjusted risk ratio, 2.0; 95% confidence interval, 1.5 to 2.7 (P value for interaction with time interval 0.06). Conclusions-In randomized trials comparing stenting with CEA for symptomatic carotid artery stenosis, CAS was associated with a substantially higher periprocedural risk during the first 7 days after the onset of symptoms. Early surgery is safer than stenting for preventing future stroke. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT00190398; URL: http://www.controlled-Trials.com. Unique identifier: ISRCTN57874028; Unique identifier: ISRCTN25337470; URL: http://www.clinicaltrials.gov. Unique identifier: NCT00004732.

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KW - carotid artery

KW - carotid artery diseases

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