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In patients with contralateral occlusion, carotid endarterectomy (CEA) yields equivalent outcomes compared with carotid artery stenting (CAS), according to new data presented June 9, 2012, at the annual meeting of the Society for Vascular Surgery (SVS) in Washington, DC.
Joseph J. Ricotta II, MD, MS, of Emory University School of Medicine (Atlanta, GA), and colleagues evaluated patients with and without contralateral occlusion in the SVS Vascular Registry who underwent CEA (n = 11,614) and CAS (n = 6,826) between November 2001 and November 2011. Contralateral occlusion was present in 5.7% of CEA patients and 16.5% of CAS patients.
In patients with contralateral occlusion, the primary endpoint (composite of periprocedural death, stroke, or MI) was similar for both interventions. This equivalence was maintained when the patients were segregated by symptom status and after adjusting for periprocedural risk (table 1).
Table 1. Periprocedural Outcomes in Patients with Contralateral Carotid Occlusion
CAS(n = 1,128)
CEA(n = 666)
In patients who underwent CEA, patients without contralateral occlusion fared better than those who did have such lesions with regard to periprocedural MACE (1.76% vs. 4.20%) and stroke (1.06% vs. 3.15%; P < 0.0001 for both). The increase in stroke driven by contralateral occlusion was seen in both asymptomatic (0.68% vs. 2.00%; P = 0.0095) and symptomatic (1.68% vs. 4.89%; P = 0.0012) patients who underwent CEA.
However, in those who underwent CAS, contralateral occlusion did not affect outcomes (table 2).
Table 2. Periprocedural Outcomes in CAS Patients
Without Contralateral Occlusion(n = 5,698)
With Contralateral Occlusion(n = 1,128)
Results of all patients with contralateral occlusion are within acceptable American Hospital Association Guidelines, the investigators report.
Patient Selection Is Key
“What we concluded was that contralateral occlusion in and of itself should not be used as a qualifying factor to say a patient is at high surgical risk, because these patients do just as well with carotid endarterectomy as carotid stenting,” Dr. Ricotta told TCTMD in a telephone interview. Based on the current data, such patients should no longer be considered at high risk, he said.
Dr. Ricotta pointed out that this trial is the largest so far to study patients with contralateral occlusion, as prior studies have just included 20 or 25 patients. “So these are huge, huge numbers and there’s significant impact here,” he said.
In terms of operator experience, Dr. Ricotta said that vascular surgeons did about 90% of the CEA procedures but only 60% of CAS procedures in the SVS registry. Radiologists and cardiologists each performed about 15% of CAS cases. “Certainly the data have shown that there’s a significant learning curve for carotid stenting and the more you do, the better your results are,” he noted. “Patient selection is very important and people who [perform both procedures] are the best to say who gets what treatment.”
Going forward, any trial looking at carotid intervention should stratify subjects according to contralateral occlusion, Dr. Ricotta said, adding that without this classification, the data will not be comparable.
“The impression out there is that everyone with carotid occlusion should get a stent because . . . they’re so high risk for endarterectomy,” he concluded. “I’d like to dispel that myth and say that some patients might be better with a stent, some better with surgery; it’s all about individual patient selection, and that’s really up to the operator.”
CAS patients were more often symptomatic and had higher prevalence of coronary artery disease, congestive heart failure, diabetes, COPD, and New York Heart Association functional class greater than 3.
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