Stenting versus endarterectomy for treatment of carotid-artery stenosis

Thomas G. Brott, Robert W. Hobson, George Howard, Gary S. Roubin, Wayne M. Clark, William Brooks, Ariane Mackey, Michael D. Hill, Pierre P. Leimgruber, Alice J. Sheffet, Virginia J. Howard, Wesley S. Moore, Jenifer H. Voeks, L. Nelson Hopkins, Donald E. Cutlip, David J. Cohen, Jeffrey J. Popma, Robert D. Ferguson, Stanley N. Cohen, Joseph L. BlackshearFrank L. Silver, J. P. Mohr, Brajesh K. Lal, James F. Meschia

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Abstract

BACKGROUND: Carotid-artery stenting and carotid endarterectomy are both options for treating carotid-artery stenosis, an important cause of stroke. METHODS: We randomly assigned patients with symptomatic or asymptomatic carotid stenosis to undergo carotid-artery stenting or carotid endarterectomy. The primary composite end point was stroke, myocardial infarction, or death from any cause during the periprocedural period or any ipsilateral stroke within 4 years after randomization. RESULTS: For 2502 patients over a median follow-up period of 2.5 years, there was no significant difference in the estimated 4-year rates of the primary end point between the stenting group and the endarterectomy group (7.2% and 6.8%, respectively; hazard ratio with stenting, 1.11; 95% confidence interval, 0.81 to 1.51; P = 0.51). There was no differential treatment effect with regard to the primary end point according to symptomatic status (P = 0.84) or sex (P = 0.34). The 4-year rate of stroke or death was 6.4% with stenting and 4.7% with endarterectomy (hazard ratio, 1.50; P = 0.03); the rates among symptomatic patients were 8.0% and 6.4% (hazard ratio, 1.37; P = 0.14), and the rates among asymptomatic patients were 4.5% and 2.7% (hazard ratio, 1.86; P = 0.07), respectively. Periprocedural rates of individual components of the end points differed between the stenting group and the endarterectomy group: for death (0.7% vs. 0.3%, P = 0.18), for stroke (4.1% vs. 2.3%, P = 0.01), and for myocardial infarction (1.1% vs. 2.3%, P = 0.03). After this period, the incidences of ipsilateral stroke with stenting and with endarterectomy were similarly low (2.0% and 2.4%, respectively; P = 0.85). CONCLUSIONS: Among patients with symptomatic or asymptomatic carotid stenosis, the risk of the composite primary outcome of stroke, myocardial infarction, or death did not differ significantly in the group undergoing carotid-artery stenting and the group undergoing carotid endarterectomy. During the periprocedural period, there was a higher risk of stroke with stenting and a higher risk of myocardial infarction with endarterectomy. (ClinicalTrials.gov number, NCT00004732.).

Original languageEnglish (US)
Pages (from-to)11-23
Number of pages13
JournalNew England Journal of Medicine
Volume363
Issue number1
DOIs
StatePublished - Jul 1 2010

ASJC Scopus subject areas

  • Medicine(all)

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    Brott, T. G., Hobson, R. W., Howard, G., Roubin, G. S., Clark, W. M., Brooks, W., Mackey, A., Hill, M. D., Leimgruber, P. P., Sheffet, A. J., Howard, V. J., Moore, W. S., Voeks, J. H., Hopkins, L. N., Cutlip, D. E., Cohen, D. J., Popma, J. J., Ferguson, R. D., Cohen, S. N., ... Meschia, J. F. (2010). Stenting versus endarterectomy for treatment of carotid-artery stenosis. New England Journal of Medicine, 363(1), 11-23. https://doi.org/10.1056/NEJMoa0912321