Carotid Artery Stenting Is Equivalent to Carotid Artery Endarterectomy When Performed by A Vascular Surgeon
Muhammad Rizwan, MD, Tru Dang, Besma Nejim, MBChB, MPH, Widian Alshwaily, MBChB, Hanaa D. Aridi, MD, Mahmoud Malas, MD, MHS.
Johns Hopkins Bayview Medical Center, Baltimore, MD, USA.
OBJECTIVES: Carotid artery endarterectomy (CEA) and Carotid artery stenting (CAS) are two effective treatment options in stroke prevention. CREST reported higher 30-day stroke and death rates following stenting. This study presents short and long-term outcomes of CEA and CAS performed at by a single vascular surgeon.
METHODS: We retrospectively reviewed all patients who underwent CEA and CAS from September 2005-June 2017 by a single surgeon. Student t-test, chi-square and fisher’s exact tests were employed to compare patients’ demographics and baseline characteristics. Postoperative stroke, MI, death and long-term outcomes of restenosis, stroke and death were compared between two groups using survival and cox-regression analyses.
RESULTS: : A total 313 procedures were performed including (CEA: 47%, CAS: 53%). In general, we take conservative approach when considering patients for intervention; therefore, all patients had 70-99% stenosis on duplex (PSV>240 cm/sec and EDV>100 cm/sec or ratio>4.0). Patients’ age [Mean (SD)68.7(3.3) vs. 69.8(2.9)] and gender (Males 63.5% vs. 54.6%) were similar between CEA and CAS, respectively (all P>0.05). Patients undergoing CAS were more likely to be symptomatic (40.6% vs. 27.7%, P=0.02) and had significantly higher comorbidities (COPD, CHF, hyperlipidaemia and prior ipsilateral intervention). No difference was seen in thirty-day complications after CEA vs. CAS including stroke (2.0% vs. 1.2%), MI (0.7% vs. 1.2%), death (0% vs.1.2%) and combined MAEs (2.7% vs.3.0%) (all P>0.05). Mean follow-up time was 3.3± 3.1 years. Overall 7-years survival and restenosis were similar between two groups, however, stroke-free survival was higher after CAS (Figure 1). After adjusting for patients’ demographics and comorbidities, there was no significant difference in long-term restenosis [HR (95%CI):0.68(0.37-1.22), P=0.19], stroke [HR (95%CI):0.33(0.10-1.04), P=0.06] and mortality [HR (95%CI):0.90(0.44-1.85), P=0.77] between CAS and CEA. Significant predictors of death/stroke were diabetes [HR(95%CI): 2.19(1.18-4.09)], CKD [HR(95%CI): 2.76(1.22-6.26)] and COPD [HR(95%CI): 3.93(1.99-7.73)] (all P-values <0.05). Statins were protective with 73% reduction in risk of death/stroke [HR(95%CI): 0.27(0.14-0.54), P<0.001].
CONCLUSIONS: Our experience showed comparable short and long-term outcomes of CAS and CEA. This was the result of proper patients’ allocation for conservative management vs. CEA or CAS, optimal perioperative medical management and the use of safe and innovative surgical and endovascular techniques. 
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