Immediate and delayed procedural stroke or death in stenting versus endarterectomy for symptomatic carotid stenosis

Mandy D. Müller, Stefanie Von Felten, Ale Algra, Jean Pierre Becquemin, Martin Brown, Richard Bulbulia, David Calvet, Hans Henning Eckstein, Gustav Fraedrich, Alison Halliday, Jeroen Hendrikse, John Gregson, George Howard, Olav Jansen, Jean Louis Mas, Thomas G. Brott, Peter A. Ringleb, Leo H. Bonati

Research output: Contribution to journalArticle

7 Scopus citations

Abstract

Background and Purpose: Stenting for symptomatic carotid stenosis (carotid artery stenting [CAS]) carries a higher risk of procedural stroke or death than carotid endarterectomy (CEA). It is unclear whether this extra risk is present both on the day of procedure and within 1 to 30 days thereafter and whether clinical risk factors differ between these periods. Methods: We analyzed the risk of stroke or death occurring on the day of procedure (immediate procedural events) and within 1 to 30 days thereafter (delayed procedural events) in 4597 individual patients with symptomatic carotid stenosis who underwent CAS (n=2326) or CEA (n=2271) in 4 randomized trials. Results: Compared with CEA, patients treated with CAS were at greater risk for immediate procedural events (110 versus 42; 4.7% versus 1.9%; odds ratio, 2.6; 95% CI, 1.9-3.8) but not for delayed procedural events (59 versus 46; 2.5% versus 2.0%; odds ratio, 1.3; 95% CI, 0.9-1.9; interaction P=0.006). In patients treated with CAS, age increased the risk for both immediate and delayed events while qualifying event severity only increased the risk of delayed events. In patients treated with CEA, we found no risk factors for immediate events while a higher level of disability at baseline and known history of hypertension were associated with delayed procedural events. Conclusions: The increased procedural stroke or death risk associated with CAS compared with CEA was caused by an excess of events occurring on the day of procedure. This finding demonstrates the need to enhance the procedural safety of CAS by technical improvements of the procedure and increased operator skill. Higher age increased the risk for both immediate and delayed procedural events in CAS, mechanisms of which remain to be elucidated.

Original languageEnglish (US)
Pages (from-to)2715-2722
Number of pages8
JournalStroke
Volume49
Issue number11
DOIs
StatePublished - 2018

Keywords

  • Carotid stenosis
  • Endarterectomy
  • Risk
  • Stents
  • Stroke

ASJC Scopus subject areas

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

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    Müller, M. D., Von Felten, S., Algra, A., Becquemin, J. P., Brown, M., Bulbulia, R., Calvet, D., Eckstein, H. H., Fraedrich, G., Halliday, A., Hendrikse, J., Gregson, J., Howard, G., Jansen, O., Mas, J. L., Brott, T. G., Ringleb, P. A., & Bonati, L. H. (2018). Immediate and delayed procedural stroke or death in stenting versus endarterectomy for symptomatic carotid stenosis. Stroke, 49(11), 2715-2722. https://doi.org/10.1161/STROKEAHA.118.020684