Meta-analyses Explore Cerebrovascular Protection, TIA and Stroke Risk with Carotid Stenting

Data from two meta-analyses presented at TCT 2014 addressed carotid intervention, particularly the efficacy of proximal occlusion vs. distal filter for cerebral protection during carotid artery stenting (CAS), and whether staged carotid stenting with CABG is noninferior to carotid endarterectomy (CEA) with CABG.

In an analysis of five randomized controlled trials and one case-control study of 292 patients undergoing transfemoral-protected CAS, Salvatore Cassese, MD, of Deutsches Herzzentrum in Munich, Germany, reported that the use of proximal occlusion vs. distal filter did not affect the incidence of new cerebral lesions or the risk of death or a cerebrovascular event. All studies utilized diffusion-weighted MRI before and after stenting, not only in cases of complication. New cerebral lesions were detected in 49% of patients after protected stenting, and death or a cerebrovascular event occurred in 3.7%. Sensitivity analysis confirmed a relationship between stenosis severity at baseline (>84.3%) and efficacy of proximal occlusion for the prevention of new cerebral and ipsilateral lesions (OR 0.15; 95% CI 0.05-0.42 for both). Additionally, studies with a higher number of symptomatic patients at baseline (>62.5%) reported decreased efficacy of proximal occlusion, yielding no protection against new cerebral lesions (OR 1.75; 95% CI 0.74-4.15).

Staged vs. combined procedures

Results of a second meta-analysis presented during the same session demonstrated that combined CEA and CABG may not be superior to staged CAS followed by CABG for carotid and coronary revascularization.

Daniel Garcia, MD, of the University of Miami Miller School of Medicine in Miami, Fla., reported a meta-analysis of four studies — one randomized controlled trial and three cohort studies — conducted between 1990 and September 2014. Overall, there was a lower prevalence of transient ischemic attack (TIA) and stroke among patients receiving staged CAS and CABG vs. combined CEA and CABG (see Figure). Additionally, there was no difference in 30-day mortality between the two methods (12 events for CAS plus CABG vs. 20 for CEA/CABG).

“CAS has an important role in treating carotid disease, and randomized studies should be pursued,” Garcia said.

“I think a hybrid procedure combining experienced interventional cardiologists and cardiothoracic surgeons is the future and will probably produce good outcomes,” he said.

Disclosures:

Cassese and Garcia report no relevant conflicts of interest.