Data from a national registry suggest that outcomes at 30 days are
better with carotid endarterectomy (CEA) than with carotid artery
stenting (CAS) [1]. Investigators report that the combined rate of
death, stroke, and MI was significantly lower with the surgical
approach vs the less invasive interventional technique.

"The debate about the interpretation of the results of this study as
well as results of other CAS studies will continue until randomized
trials such as International Carotid Stenting Study (ICSS) in Europe
and [the Carotid Revascularization Endarterectomy vs Stenting Trial]
CREST in North America are reported," note lead investigator Dr Anton
Sidawy (Washington Veterans Affairs Medical Center, DC) and
colleagues in the January 2009 issue of the Journal of Vascular
Surgery.

The data, from the Society for Vascular Surgery (SVS), are the latest
in a number of head-to-head comparisons between CEA and CAS that have
often shown conflicting results. Two carotid-artery stenting studies--
Stent-Supported Percutaneous Angioplasty of the Carotid Artery versus
Endarterectomy (SPACE) [2] and Endarterectomy versus Angioplasty in
Patients with Symptomatic Severe Carotid Stenosis (EVA-3S) [3]--were
published in 2006, and both showed stenting to be inferior to
endarterectomy.

Those findings contrasted with data from the Stenting and Angioplasty
with Protection in Patients at High Risk for Endarterectomy
(SAPPHIRE) trial, a study that compared carotid stenting using distal
embolic protection with carotid endarterectomy in patients at high
surgical risk [4]. Based on the findings from SAPPHIRE, the Food and
Drug Administration approved the use of carotid stenting in patients
with high-grade symptomatic stenosis who are at high operative risk.

In this analysis, the researchers obtained data from the SVS vascular
registry for carotid procedures. Rates of death, stroke, and MI were
significantly higher among patients who underwent stenting compared
with those had an endarterectomy. Both symptomatic and asymptomatic
patients had significantly higher 30-day procedure rates of death,
stroke, and MI compared with CEA patients. Similarly, in an analysis
of only patients with atherosclerosis, the death, stroke, and MI
combined end point was significantly lower among those who underwent
CEA.

Highlighting the inconsistencies in the field, the 5.72% event rate
among CAS patients is consistent with outcomes observed in the BEACH
and MAVERIC studies, higher than that observed in SAPPHIRE and other
studies, and lower than that observed in the ARCHER and CAPTURE
trials.

More data are expected sometime this year with the results of CREST,
a study of 2511 asymptomatic and symptomatic patients who are not at
high risk for surgery. The ICSS study is a head-to-head comparison of
carotid stenting and endarterectomy in approximately 1700
asymptomatic patients with carotid stenosis.

The researchers note that the SVS registry could possibly supplement
randomized trials "by providing real-world comparisons of CAS and
CEA," especially in important patient subsets.


Sidawy AN, Zwolak RM, White RA, et al. Risk-adjusted 30-day outcomes
of carotid stenting and endarterectomy: results from the SVS vascular
registry. J Vasc Surg 2009; 49:71-79. Abstract
Space Collaborative Group. 30-day results from the SPACE trial of
stent-protected angioplasty versus carotid endarterectomy in
symptomatic patients: a randomised non-inferiority trial. Lancet
2006; 368:1239-1247. Abstract
Mas JL, Chatellier G, Beyssen B. Endarterectomy versus stenting in
patients with symptomatic severe carotid stenosis. N Engl J Med 2006;
355:1660-1671. Abstract
Yadav JS, Wholey MH, Kuntz RE. Protected carotid-artery stenting
versus endarterectomy in high-risk patients. N Engl J Med 2004;
351:1493-50. Abstract