Originally published by 2 Minute Medicine® (view original article). Reused on AccessMedicine with permission.

1. 1% of patients in CAS and CEA had disabling stroke or mortality, whereas 2% in both group had non-disabling procedural strokes.

2. The rate of non-procedural stroke was similar between symptomatic and asymptomatic patients, irrespective of procedure (p=0.21).

Evidence Rating Level: 1 (Excellent)

Study Rundown:

Carotid artery stenosis is primarily managed via carotid artery stenting (CAS) or carotid endarterectomy (CEA). Severe stenosis can increase the likelihood of stroke, making it crucial to identify and manage asymptomatic patients. Until now, limited research has been conducted to compare the relative efficacies between each procedure. This randomized controlled trial aimed to assess the long-term safety and efficacy of carotid artery stenting versus carotid endarterectomy for patients with severe carotid artery stenosis. The co-primary outcomes for this study were all-cause mortality (within 30 days of intervention) and stroke. According to study results, both procedures were comparable in the rate of mortality and stroke (after 30 days and at the 5-year follow-up). The rates of non-procedural strokes were also similar between symptomatic and asymptomatic patients, regardless of the intervention received. This study was strengthened by a large sample size (>1000 patients per group) with longitudinal assessment (>1 year), thus increasing its validity.

In-depth [randomized controlled trial]:

From Jan 15, 2008, to Dec 31, 2020, 3625 patients were enrolled and randomly assigned (1811 to CAS and 1814 to CEA) across 130 centers in 33 countries. Included were those with severe unilateral or bilateral carotid artery stenosis (>60% on ultrasound) and both doctor and patient agreement to a carotid procedure for further management. Patients were assessed for 30 days after the intervention and at the five-year follow-up. Most of them were male (70%) and an equal proportion were ≥70 years old.

The primary outcome of mortality or disabling stroke was comparable between patients in both groups. For instance, 1% of patients in CAS (n=17 of 1653) and 0.9% of patients in CEA (n=15 of 1788) had disabling stroke or mortality, whereas 2% (48 in CAS and 29 in CEA) had non-disabling procedural stroke. At the five-year follow-up, mild differences were noted, with a greater predisposition to any stroke among CAS patients (5.3%) than CEA patients (4.5%), (rate ratio [RR] 1.16, 95% confidence interval [CI] 0.86-1.57, p=0.33). The rate of non-procedural stroke in symptomatic and asymptomatic patients was similar, irrespective of procedure (RR 1.11, 95% CI 0.91-1.32, p=0.21). Findings from this study suggest that both CAS and CEA have similar long-term clinical efficacies in high-risk patients with carotid artery stenosis.

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