Patients with symptomatic stenosis of the internal carotid artery benefit from early intervention. The challenge lies in what intervention to choose.  Most studies comparing endarterectomy to carotid stenting are fairly heterogeneous as regards timing of intervention. This element is key to comparing between procedures, since there is no doubt timing will directly affect results.

This study assessed the relationship between timing of intervention (0-7 days or >7 days after a neurological event) and the risk of stroke, death at 30 days after the two revascularization treatments (endarterectomy and carotid stenting).

It included all patients from 4 randomized studies from the “Carotid Stenosis Trialists Collaboration”. Of 4138 patients, a minority received revascularization within a week of symptom onset (14% of patients undergoing carotid stenting and 11% of patients undergoing endarterectomy).

Among patients treated before a week prior to symptoms, those undergoing carotid stenting had a higher risk of stroke or death compared to those undergoing endarterectomy (8.3% vs 1.3%, RR 6.7; CI 95% of 2.1 to 21.9), and this after adjusting for sex, age and severity of original neurological symptom.

For interventions after the first week, carotid stenting also showed higher risk, though not as much for those that received early intervention (7.1% vs 3.6%, RR 2.0; CI 95% of 1.5 to 2.7).

Conclusion

In this pool of randomized studies comparing carotid stenting to endarterectomy in symptomatic patients with internal carotid lesions, carotid stenting showed higher periprocedural risk, especially within seven days of index event.

Early surgery resulted safer to prevent future stroke in this group of patients.

Editorial Comment

Study outcomes assessing medical treatment showed significant reduction of events with aspirin, clopidogrel and statins. However, it was not enough. The best medical treatment should be associated to early revascularization. The question is what to choose.

A recent analyzis showed more than 56,000 patients of the German registry with severe symptomatic left carotid lesions did not show significant differences between those very early intervened (within 48 hours) and the ones intervened after the event (risk of stroke and death between days 0-2 of 3%, between days 3-7 of 2.5%, between days 8-14, 2.6%, and beyond day 14, 2.3%).

No large randomized study was used at the time of treatment as randomization criteria, which is why we should do with post-hoc analyzis comparing both strategies.

The differences between the CREST and the other 3 randomized studies (EVA-3S, ICSS and SPACE) could be due to the different stratification of time, which is why the question regarding which treatment is better for symptomatic patients seems to have no definite answer, even though, for now, surgery seems to be winning.

Original Title: Early Endarterectomy Carries a Lower Procedural Risk Than Early Stenting in Patients With Symptomatic Stenosis of the Internal Carotid Artery. Results From 4 Randomized Controlled Trials.

Reference: Barbara Rantner et al. Stroke. 2017;48:00-00 (Epub ahead of print).

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