Carotid surgery outperforms stenting in patients 75+ years

Patients aged ≥75 years are at a higher likelihood of having poor outcomes after carotid artery stenting (CAS) than carotid endarterectomy (CEA), according to a combined analysis of two studies with over 2,500 patients.

CAS expands the carotid artery through insertion of a stent whereas CEA is a surgical procedure to remove plaque deposits in the carotid artery and increase blood flow to the brain. More recently, CAS has emerged as an alternative to CEA in patients with cerebral large artery disease. Age has been shown to be an effect modifier for CAS with older patients at a higher risk, but not for CEA.

The analysis included data from 2,544 elderly asymptomatic patients from CREST* (n=1,091) and  ACT I (n=1,453) trials with ≥70 percent carotid stenosis and treated with CAS or CEA, on top of standard management for cardiovascular risk factors. Patients from CREST had no age ceiling; those from ACT 1 were 79 years or younger. [ISC 2020, abstract 70]

The prespecified primary outcome was the combined incidence of periprocedural stroke, myocardial infarction [MI], or death, or any incidence of ipsilateral stroke within 4 years after randomization. Among patients who underwent CAS, the incidence of the primary outcome was 30 percent higher among patients aged 65–74 years vs patients aged <65 years, but the difference was not statistically significant.

However, patients aged 75+ years  were at a substantially higher risk (hazard ratio [HR], 2.9; p=0.001). By contrast, the risk did not differ by age in patients who underwent CEA.

Largest data set for CAS, CEA

The risk for poor outcomes in patients who underwent CAS “abruptly increased around age 75” vs patients who underwent CEA, and these results mirror the findings from a similar combined analysis of data from four major randomized trials that compared CEA and CAS in patients with symptomatic carotid disease, said study author Dr Jenifer Voeks, a neurology researcher at the Medical University of South Carolina in Charleston, South Carolina, US. She added their analysis has the largest dataset thus far to compare CAS and CEA by age in asymptomatic patients.

Which patient would benefit from CAS?

 “CAS appears to be a reasonable alternative to CEA in patients ≤70 years, but in those aged 70 years, and certainly in those above age 75, age-related risk factors such as cerebrovascular anatomy and underlying cerebral pathology should be carefully considered before selecting patients for CAS,” Voeks said.

Commenting on the findings, Dr Mai Nguyen-Huynh, a vascular neurologist from Kaiser Permanente Northern California in Oakland, California, US, said it’s not surprising that  CEA did better than CAS in the analysis. There is already evidence that CAS does not perform as well as CEA in older patients with symptomatic carotid artery disease, likely because older patients have more fragile and torturous blood vessels that make CAS more challenging and raise the potential for more adverse events, she said.

As more and more experts have been turning to new drugs as a treatment option for patients with advanced atherosclerotic carotid artery disease, this has turned into a state of “equipoise” for pharmacological vs interventional management, she added. CREST 2** would attempt to compare CEA and CAS with medical management, and results are expected in 2021.