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Hot Line - Carotid endarterectomy or carotid stenting for asymptomatic severe carotid stenosis?

29 Aug 2021
Hot Line presented at ESC Congress

Until now, few data existed on the comparative long-term effectiveness of carotid endarterectomy (CEA) compared with carotid stenting (CAS) for stroke prevention in patients with asymptomatic carotid stenosis for whom a carotid procedure is considered necessary.

In a Hot Line session today, Professor Alison Halliday (University of Oxford, UK) presented results from the large international ACST-2 trial, in which 3,625 patients with asymptomatic carotid stenosis (≥60% reduction in diameter on ultrasound) and no recent ipsilateral symptoms were randomised to CEA or CAS and followed up for an average of 5 years.

One of the main outcomes was the incidence of procedural risks: 1% of patients in both groups had a disabling stroke or died within 30 days (15 allocated to CAS and 18 to CEA) and 2% had a non-disabling procedural stroke (48 allocated to CAS and 29 to CEA).

There was also no difference between the groups for the other main outcome, 5-year prevention of non-procedural stroke. Fatal or disabling stroke occurred in 2.5% of patients in each group, with a rate ratio (RR) for CAS vs. CEA of 0.98 (95% confidence interval [CI] 0.64 to 1.48; p=0.91). Any non-procedural stroke occurred in 5.3% of the CAS group vs. 4.5% of the CEA group (RR 1.16; 95% CI 0.86–1.57; p=0.33).

A meta-analysis of this and all other major trials of CAS vs. CEA yielded a similarly non-significant result for any stroke (RR 1.11; 95% CI 0.91–1.32; p=0.21).

Prof. Halliday commented: “We have shown that, for patients with a severely narrowed carotid artery, stenting and surgery have similar effects on the chances of having a disabling or fatal stroke.” Discussing the long-term risk of a disabling or fatal stroke in these patients, she said, “The risk from each procedure is about 1%. After that, however, the annual risk over the next 5 or more years is halved, from 1% down to 0.5% per year.”


Missed the session? Watch it on demand: