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September 10th, 2010

Meta-Analysis Finds High Risk for Carotid Stenting in Older Patients

Carotid stenting should not be performed in patients age 70 years or older, according to the results of a new meta-analysis appearing in the Lancet. Researchers in the Carotid Stenting Trialists’ Collaboration combined data from 3433 patients with symptomatic carotid stenosis who were randomized to either endarterectomy or stenting in the EVA-3S, SPACE, and ICSS trials.

At 120 days after randomization, the rate of stroke or death was higher in the stenting group than in the endarterectomy group (8.9% versus 5.8%, RR 1.53, p=0.0006). However, there was no difference between the groups among patients younger than age 70, while in patients age 70 or older, stenting was associated with double the risk associated with endarterectomy:

  • Younger than age 70, stenting versus endarterectomy: 5.8% versus 5.7%
  • Age 70 or older, stenting versus endarterectomy: 12% versus 5.9%, RR 2.04, p=0.0014

A similar pattern was observed in a per-protocol analysis after 30 days restricted to patients who received the allocated treatment:

  • Younger than age 70, stenting versus endarterectomy: 5.1% versus 4.5%
  • Age 70 or older, stenting versus endarterectomy: 10.5% versus 4.4%

The authors write that their “findings suggest that stenting might… be a viable alternative to endarterectomy in younger patients, in whom surgery could otherwise be undertaken without increased risk,” although they express concern about the long-term stroke risk in young patients treated with stents due to “the potentially higher rate of recurrent stenosis after stenting than with endarterectomy.”

Categories: Cardiac Surgery
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One Response to “Meta-Analysis Finds High Risk for Carotid Stenting in Older Patients”

  1. William L Blanchet, MD says:
    September 11, 2010 at 12:18 pm

    Where is the control group of medical management without any procedure?

    This is useful information however it is implying that some intervention benefits the subjects. I question this assumption and we need some good DATA to show if and when endarterectomy or stenting adds value in carotid disease in the age of excellent medications to mitigate risk.