Which Carotid Repair for Symptomatic, Severe Carotid Stenosis?

Which Carotid Repair for Symptomatic, Severe Carotid Stenosis?

Endarterectomy beat stenting in symptomatic patients with stenoses of at least 60%.

Carotid endarterectomy (CEA) is the standard treatment for severe, symptomatic carotid stenosis. Carotid stenting is gaining popularity as an alternative to CEA, but questions remain about the relative benefits of the two procedures.

Researchers in France conducted a publicly funded, multicenter, randomized trial to assess the noninferiority of carotid stenting to CEA. Eligible patients had stenoses of 60% to 99% in a symptomatic carotid artery and had experienced a stroke or transient ischemic attack (TIA) within the previous 120 days. The trial, known as EVA-3S, was stopped early, in part because CEA had clear early advantages. Results are reported for 520 patients (mean age, 70; 75% men). An embolic-protection device was used in 92% of the stenting group.

CEA had significant advantages over stenting in the 30-day incidences of any stroke or death (3.9% vs. 9.6%) and of nonfatal stroke (2.7% vs. 8.8%). Only one disabling stroke occurred in the CEA group, compared with seven in the stenting group. Thirty-day mortality was similar in the two groups. Cranial-nerve injury was significantly more common with CEA than with stenting (7.7% vs. 1.1%). At 6 months, CEA still retained a significant advantage in the incidence of any stroke or death (6.1% vs. 11.7%), as well as in the combined incidence of any or stroke or death at 30 days plus ipsilateral stroke between 31 days and 6 months (4.2% vs. 10.2%).

Comment: In this randomized trial, endarterectomy had clear advantages over stenting in patients with severe, symptomatic carotid stenosis and recent stroke or TIA. The findings are consistent with data from the recent SPACE trial, which failed to prove the noninferiority of stenting (Journal Watch Cardiology Oct 18 2006). The FDA has approved carotid stenting for symptomatic stenosis >70%, largely on the basis of data from the SAPPHIRE trial (Journal Watch Cardiology Nov 19 2004). An editorialist reminds us that the SAPPHIRE subjects had high surgical risk, most often due to clinical coronary disease. Given the existing evidence, consideration of carotid stenting should be reserved for patients in need of carotid repair who have a symptomatic stenosis >70% and high surgical risk.

— Harlan M. Krumholz, MD, SM

Published in Journal Watch Cardiology December 27, 2006

Citation(s):

Mas J-L et al. for the EVA-3S Investigators. Endarterectomy versus stenting in patients with symptomatic severe carotid stenosis. N Engl J Med 2006 Oct 19; 355:1660-71.