5 - Executive Committee for the Asymptomatic Carotid AtherosclerosisStudy. Endarterectomy for asymptomatic carotid artery stenosis. JAMA 1995 ; 273 : 1421-1428.
1662 patients with stenosis more than 60 % (NASCET) randomized with a following of de 2,7 years. The results shows a risk of ipsilatearl cerebral infarctus of 11 % in the non operative group, and 5,9 % in the surgery group, diminution of relatif risk of 53 % (p=0,04). the rate of peri-operative death-morbidity péri-opératoirewas 2,3 %, including complications of arteriography. The factors of higher morbi-mortality were previous cerebral stroke, controlatéral stenosis > 60 %, diabet, sténosis of controlateral siphon . The benefice of surgery was significant for AIT plus ipsilateral infarctus after 3 years post-operative for men - not for women - it was not significant for severe ipsilateral infarctus
6 - CREST The Carotid Revascularization Endarterectomy versus Stenting Trial : stenting versus carotid endarterectomy for carotid disease.
Stroke. 2010 Oct;41(10 Suppl):S31-4. doi: 10.1161/STROKEAHA.110.595330.
Mantese VA1, Timaran CH, Chiu D, Begg RJ, Brott TG; CREST Investigators.
randomized to CAS or CEA, symptomatic and asymptomatic patients
RESULTS There was no significant difference in the rates of the primary end point between CAS and CEA (7.2% versus 6.8%; hazard ratio, 1.11; 95% CI, 0.81 to 1.51; P=0.51). Symptomatic status and sex did not modify the treatment effect, but an interaction with age and treatment was detected (P=0.02). Outcomes were slightly better after CAS for patients aged <70 years and better after CEA for patients aged >70 years. The periprocedural end point did not differ for CAS and CEA, but there were differences in the components, CAS versus CEA (stroke 4.1% versus 2.3%, P=0.012; and myocardial infarction 1.1% versus 2.3%, P=0.032).
CONCLUSION In CREST, CAS and CEA had similar short- and longer-term outcomes. During the periprocedural period, there was higher risk of stroke with CAS and higher risk of myocardial infarction with CEA.
7 - ACT I Randomized Trial of Stent versus Surgery for Asymptomatic Carotid Stenosis
March 17, 2016 N Engl J Med 2016; 374:1011-1020 DOI: 10.1056/NEJMoa1515706
Kenneth Rosenfield, M.D., M.H.C.D.S., Jon S. Matsumura, M.D., Seemant Chaturvedi, M.D.,
trial, compare carotid-artery stenting with embolic protection and carotid endarterectomy in patients asymptomatic
RESULTS
Stenting was noninferior to endarterectomy with regard to the primary composite end point (event rate, 3.8% and 3.4%, respectively; P=0.01 for noninferiority). The rate of stroke or death within 30 days was 2.9% in the stenting group and 1.7% in the endarterectomy group (P=0.33). From 30 days to 5 years after the procedure, the rate of freedom from ipsilateral stroke was 97.8% in the stenting group and 97.3% in the endarterectomy group (P=0.51), and the overall survival rates were 87.1% and 89.4%, respectively (P=0.21). The cumulative 5-year rate of stroke-free survival was 93.1% in the stenting group and 94.7% in the endarterectomy group (P=0.44).
CONCLUSIONS
In this trial involving asymptomatic patients with severe carotid stenosis who were not at high risk for surgical complications, stenting was noninferior to endarterectomy with regard to the rate of the primary composite end point at 1 year. In analyses that included up to 5 years of follow-up, there were no significant differences between the study groups in the rates of non–procedure-related stroke, all stroke, and survival. (Funded by Abbott Vascular; ACT I
8 - Carotid Stenting Versus Endarteriectomy for Asymptomatic Carotid Aretry Stenosis : A systematic Review and Meta-analysis
Stroke 2017 Aug:48(8): 2150-2157. toi : 10.116/STROKEEAHA.117.016824. Pub 2017 Jul 5
Moresoli P, Habib B, Reynier P, Secreet MH, Eisenberg MJ, Filion KB
5 RCT (CREST 2010 : 594 patients, ACT I 2016 : 1172 patients), total 3019 patients, asymptomatic only
did not rule clinical relevant differences between CAS (angioplasty) and CEA (endarterectomy) with respect to long term strokes and the composite outcome of peri procedural stroke, death or myocardial infarction, or long term psi-lateral stroke. Our results suggest that CAS may potentially increase the risk of any peri-procedural stroke, peri-procedural non disabling stroke, and any peri-procedural stroke or death
CEA is responsable of more per-procedural cracial nerve paralysy and peri-procedural myocardial infarction
9 - Carotid Artery Stenting versus Endarteriectomye for Stroke Prevention : A Meta-Analysis of Clinical Trials
J Am Coll Cardiol 2017 May 9:69(18):2266-2275. doi: 1016/j.jacc.2017.02.053
Sardar P, Chatterjee S, Aronow HD
5 RCT , total 6526 patients, symptomatic and asymptomatic
CAS and CEA were associated with similar rates of composite of peri procedural death, stroke, MI or non preriprocedural ipsilateral stroke. The risk of long term overall stroke was significantly higher with CAS, and was mostly attributed to peri procedural minor stroke. CAS was associated with lower rates of peri-procedural MI once cranial nerve palsy than CEA
10 - Guidelines of ESC (European Society of Cardiology) & ESVS (European Society of Vascular Surgery)
11 - AHA (American Heart Association) Guidelines 2011 on management of patients with extracarnial carotid and vertebral artery disease
…indication if ipsilateral carotid artery is reduced more than 70% with non invasive imaging or more than 50% as documented by catheter angiography, and the anticipated rate of per-operative stroke or mortality is less than 6%
Carotid Bibliography
1 - Sténoses athéromateuses de la carotide interne : quelles indications ? D. Mellière, J.P. Becquemin, M. Fitoussi, F. Cervantes-Monteil . Sem Hôp Paris, 1993, 69, nº6, 162-169
2 - NASCET (North American Symptomatic Carotid Endarteriectomy Trial Collaborators)
Beneficial effect of carotid endarteriectomy in symptomatic patients with high grade carotid stenosis
New England Journal of Medecine 1991 ; 325 : 445-453
3 - ECST (European Carotid Surgery Trialist’s Collaborative Group)
MCR European carotid Surgery Trial : interim results for symptomatic patients with severe (70-99%) or with mild (0-29%) carotid stenosis.
Lancet 1991 ; 337 : 1235-1243
4 - Veteran Affairs Cooperative Study Group
Efficacity of carotid endarteriectomy for asymptomatic carotid stenosis. Hobson R.W., Weiss D.G., Fields P.D., and the Veterans Affair Cooperativ Study Group. New England Journal of Medecine 1993 ; 328 : 221-227
444 men with carotid stenosis > 50 % (NASCET). After 4 years the risk of stroke was less in the surgery group 8% (20% non surgery group), risk reduction 12,4%, relativ risk reduction 38%
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