Success Of Current Medical Management May Be Overestimated When Compared To Carotid Endarterectomy, But Not Carotid Artery Stenting When Treating Asymptomatic Carotid Artery Stenosis
Jeffery E. Indes, MD, Matthew Muller, BS, Evan C. Lipsitz, MD.
Montefiore Einstein, Bronx, NY, USA.
Objectives: Current medical management (MED) of asymptomatic carotid stenosis (ACS) has reported to improve 5-year stroke rates to 4.7%, while stroke after carotid endarterectomy (CEA) and carotid artery stenting (CAS) has remained unchanged. Although medical management in ACS patients has been associated with better outcomes during the first 30 days, CEA has been associated with significantly lower long-term rates of stroke/death at 5 years. The aim of our study was to identify current outcomes of patients with ACS treated with MED vs. those treated with CEA and CAS in a large cross-sectional cohort. Methods: TriNetX (TriNetX LLC, Cambridge, Massachusetts), a large multicenter electronic health record (EHR) database, was queried retrospectively to establish cohorts for all adults with asymptomatic carotid stenosis. ICD 10 codes were used to identify patients treated with medical management (ASA and statin), CEA or by carotid artery stenting (CAS). Primary endpoints were mortality, myocardial infarction (MI) and stroke at 5 years during the study interval (2007-2017). Propensity matching was performed, and standard statistical methods applied. Results: We identified n = 128,774 MED patients, n = 12,476 with CEA and n = 4043 with CAS. After propensity matching 5-year mortality for MED vs. CEA was 18.7% vs. 17.1% (p<0.001), MI was 13.8% vs. 11.8% (p<0.001), and stroke was 26.9% vs. 29.2% (p<0.001). After propensity matching the 5-year mortality for MED vs. CAS was 17.6% vs. 22.5% (p<0.001), MI was 14.6% vs. 12.0% (p=0.001) and stroke was 27.9% vs. 39.1% (p<0.001). The endovascular group had a significantly lower survival probability (71.14%) at 5 years compared to the propensity-matched medical management group (77.91%) (p=0.043). The open surgical management group had a significantly higher survival probability (78.77%) at 5 years compared to the propensity-matched medical management group (76.77%) (p<0.0001). Conclusion: Mortality and MI were significantly higher in MED patients at 5 years when compared to those treated with CEA, while stroke was higher in the CEA patients. When compared to CAS, patients treated with MED had significantly higher rates of MI, while the CAS patients had significantly higher rates of mortality and stroke. Survival seems to be most superior in CEA patients at 5-years when compared to MED, with CAS patients having the lowest 5-year survival, suggesting CEA should be strongly considered in appropriate asymptomatic patients.
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