Stroke/Death Rates Following Carotid Artery Stenting and Carotid Endarterectomy in Contemporary Administrative Dataset Registries: A Systematic Review

K I Paraskevas; E L Kalmykov; A R Naylor

doi:10.1016/j.ejvs.2015.07.032

Stroke/Death Rates Following Carotid Artery Stenting and Carotid Endarterectomy in Contemporary Administrative Dataset Registries: A Systematic Review

Eur J Vasc Endovasc Surg. 2016 Jan;51(1):3-12. doi: 10.1016/j.ejvs.2015.07.032. Epub 2015 Sep 4.

Authors

K I Paraskevas¹, E L Kalmykov², A R Naylor²

Affiliations

¹ St. George's Vascular Institute, St. George's Healthcare NHS Trust, London, UK. Electronic address: paraskevask@hotmail.com.
² Department of Vascular Surgery, Vascular Research Group, Division of Cardiovascular Sciences, Clinical Sciences Building, Leicester Royal Infirmary, Leicester, UK.

PMID: 26346006
DOI: 10.1016/j.ejvs.2015.07.032

Abstract

Background: Randomised trials have reported higher stroke/death rates after carotid artery stenting (CAS) versus carotid endarterectomy (CEA). Despite this, the 2011 American Heart Association (AHA) guidelines expanded CAS indications, partly because of the Carotid Revascularization Endarterectomy versus Stenting Trial, but also because of improving outcomes in industry sponsored CAS Registries. The aim of this systematic review was: (i) to compare stroke/death rates after CAS/CEA in contemporary dataset registries, (ii) to examine whether published stroke/death rates after CAS fall within AHA thresholds, and, (iii) to see if there had been a decline (over time) in procedural risk after CAS/CEA.

Methods: PubMed/Medline, Embase, and Cochrane databases were systematically searched according to the recommendations of the PRISMA statement from January 1, 2008 until February 23, 2015 for administrative dataset registries reporting outcomes after both CEA and CAS.

Results: Twenty-one registries reported outcomes involving more than 1,500,000 procedures. Stroke/death after CAS was significantly higher than after CEA in 11/21 registries (52%) involving "average risk for CEA" asymptomatic patients and in 11/18 registries (61%) involving "average risk for CEA" symptomatic patients. In another five registries, CAS was associated with higher stroke/death rates than CEA for both symptomatic and asymptomatic patients, but formal statistical comparison was not reported. CAS was associated with stroke/death rates that exceeded risk thresholds recommended by the AHA in 9/21 registries (43%) involving "average risk for CEA" asymptomatic patients and in 13/18 registries (72%) involving "average risk for CEA" symptomatic patients. In 5/18 registries (28%), the procedural risk after CAS in "average risk" symptomatic patients exceeded 10%.

Conclusions: Data from contemporary administrative dataset registries suggest that stroke/death rates following CAS remain significantly higher than after CEA and often exceed accepted AHA thresholds. There was no evidence of a sustained decline in procedural risk after CAS.

Keywords: Carotid artery stenting; Carotid endarterectomy; Registries; Stroke.

Publication types

Review
Systematic Review

MeSH terms

Aged
Angioplasty / adverse effects*
Angioplasty / instrumentation*
Angioplasty / mortality
Carotid Stenosis / complications
Carotid Stenosis / diagnosis
Carotid Stenosis / mortality
Carotid Stenosis / therapy*
Databases, Factual
Endarterectomy, Carotid / adverse effects*
Endarterectomy, Carotid / mortality
Female
Humans
Male
Middle Aged
Registries
Risk Assessment
Risk Factors
Stents*
Stroke / diagnosis
Stroke / etiology*
Stroke / mortality
Time Factors