Carotid Stenting Should Be Avoided in Older Patients

A new study recommends that stenting for symptomatic carotid stenosis in patients 70 years and older should be avoided, although the procedure might be as safe as endarterectomy in younger patients.

Researchers at University College London (United Kingdom), University Hospital Basel (Switzerland), and other institutions conducted a prospectively defined meta-analysis of individual patient data from three randomized controlled trials: the Endarterectomy versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis (EVA-3S) trial, the Stent-Protected Angioplasty versus Carotid Endarterectomy (SPACE) trial, and the International Carotid Stenting Study (ICSS).The data from the trials, comprising 3,433 patients, were pooled and analyzed, with any stroke or death as the primary outcome.

The researchers found that in the first 120 days after randomization, any stroke or death was 53% more likely to occur in the carotid stenting group, occurring in 8.9% of the patients randomly assigned to stenting, compared to 5.8% in patients randomly assigned to carotid endarterectomy. Of all subgroup variables assessed in the meta-analysis, only age significantly modified the treatment effect. While in patients younger than 70 years, the estimated 120-day risk for stroke or death was 5.8% in the carotid stenting group and 5.7% in the carotid endarterectomy group, in patients 70 years or older, the estimated risk for stroke or death was twice that with carotid endarterectomy: 12.0% versus 5.9%. The findings also suggest that stenting might be a viable alternative to endarterectomy in younger patients, although there is some uncertainty about the potentially higher rate of recurrent stenosis after stenting, and the implications this might have for future stroke risk in these patients. The study was published early online on September 10, 2010, in the Lancet.

"There is strong evidence that, in the short term, the harm of stenting compared with endarterectomy decreases with younger age,” concluded lead author Martin Brown, M.D., and colleagues of the carotid stenting trialists' collaboration. "An approach of offering stenting when technically feasible as an alternative option to endarterectomy to patients younger than 65-70 years with symptomatic carotid stenosis, in centers in which acceptable periprocedural outcomes have been independently verified, might seem justified, as long as patients are made aware of a possible increase in the risk of restenosis.”

Related Links:
University College London
University Hospital Basel