Carotid Interventions For Asymptomatic Patients With High Grade Carotid Stenosis Do Not Confer Any Long-term Benefits Over Conservative Management
Becky Long, MD, Rabih A. Chaer, MD, Bryan Wu, Natalie D. Sridharan, MD, Elizabeth Genovese, MD, Mohammad H. Eslami, MD MPH, Michel S. Makaroun, MD, Efthymios D. Avgerinos, MD.
UPMC, PITTSBURGH, PA, USA.
Objective(s): Carotid endarterectomy (CEA) has been established as the treatment of choice for asymptomatic patients with significant carotid stenosis, however accumulating evidence suggests that current best medical treatment alone may be sufficient to prevent stroke. Carotid artery stenting (CAS) is also emerging as an alternative for this subset of patients. This study assesses the long-term stroke and mortality rates among these three treatment alternatives.Methods: Consecutive patients who underwent CEA or CAS for asymptomatic carotid disease between 2006 and 2012, were identified through electronic medical records. Electronic vascular lab records were searched for carotid duplex studies on asymptomatic patients with a 70-99% stenosis who had at least 1-year follow up without receiving a carotid intervention (conservative management (CM) group). Thirty day outcomes of those who underwent an intervention and 5-year risks of stroke and death for all three groups were analyzed. Chi -square, Kaplan Meier and cox regression analysis were used. Results: 808 CEA, 65 CAS and 70 CM patients fulfilled inclusion criteria. At baseline, demographics and comorbidities were similar among groups with the exception of age (71. 6±8. 7 CEA, 69. 6±8. 4 CAS, 74. 4±9. 9 CM, P= . 006) and coronary artery disease (47. 7% CEA, 64. 5% CAS, 49. 3% CM, P=. 035). 72. 2% of CEA, 69. 2% of CAS and 61. 4% of CM patients were on statins (P= . 154). 22/70 CM patients had a carotid intervention during the follow up, one because of symptomatic conversion. Perioperative stroke/death and myocardial infarction were 1. 6% and 1. 6% for CEA, 1. 5% and 0 for CAS respectively. At 5 years, any stroke rates were 6. 0%, 1. 7% and 7. 2% for CEA, CAS and CM respectively (log rank= . 600). Death rates at 5 years were 21. 2%, 11. 2% and 16. 3% for CEA, CAS and CM respectively (log rank= . 115). Due to the low stroke rate, regression analysis would have been underdetermined, however CM was protective compared to CEA for long term death (HR 0. 414, P= . 018).Conclusions: Carotid interventions, for asymptomatic patients with high grade (70-99%) carotid stenosis, confer small perioperative risks without any long-term benefits over conservative management. Large prospective trials are needed to identify subgroups that might benefit from intervention.
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