Stroke Risk Reduction Similar With Carotid Stenting and Endarterectomy

September 3, 2021
By Walter Alexander VIRTUAL -- September 2, 2021 -- For patients with a severely narrowed carotid artery, stenting and surgery have similar effects on the chance of having a disabling or fatal stroke, according to a study presented at the Virtual 2021 European Society of Cardiology (ESC) Congress. The second asymptomatic carotid surgery trial (ACST-2) was conducted to address uncertainty as to whether the benefits demonstrated in clinical trials of endarterectomy (50% reduced stroke over 5 years) extend to carotid stenting. “Both doctors and patients are substantially uncertain as to which to prefer,” stated Alison Halliday, MD, University of Oxford, Oxford, United Kingdom. ACST-2 included 3,625 patients with severe carotid artery narrowing (≥60% on ultrasound) found by chance and without recent stroke or other related neurological symptoms. The patients were randomised 1:1 to endarterectomy or carotid stenting and followed for an average of 5 years. The primary outcome measure was 5-year nonprocedural stroke. Procedural stroke risks, such as morbidity and mortality within 1 month after the procedure, were also tallied. Fatal or disabling stroke occurred at the same rate in both groups (2.5%), with a rate ratio (RR) for carotid stenting versus endarterectomy of 0.98 (95% confidence interval [CI], 0.64-1.48; P = .91). Nonprocedural stroke rates were 5.3% in the carotid stenting group and 4.5% in the endarterectomy group (RR = 1.16; 95% CI, 0.86-1.57; P = .33); when data were included in a meta-analysis of major trials of carotid stenting versus endarterectomy, the difference was similarly nonsignificant for any stroke (RR = 1.11; 95% CI, 0.91-1.32; P = .21). In regard to procedural risks, Dr. Halliday said that 1% of patients in both groups had a disabling stroke or died within 30 days (15 stented group and 18 endarterectomy group), and 2% had a non-disabling stroke (48 and 29 patients, respectively). ACST-2 is the largest trial to compare long-term stroke with carotid stenting versus endarterectomy in stroke-naive asymptomatic patients with a severely narrowed carotid artery. It showed that carotid stenting and endarterectomy involve similar risks and benefits and, when competently performed, involve about a 1% risk of causing disabling stroke or death. Both interventions reduced future stroke risk in half. “Patients should all be given good medical treatment to reduce stroke risk, but adding carotid stenting or endarterectomy may also be appropriate,” Dr. Halliday concluded. [Presentation title: Carotid Artery Surgery and Stenting Have Similar Long-Term Effects on Stroke]