In the majority of trials performed to date, carotid stenting has been associated with a higher periprocedural risk of stroke than endarterectomy, particularly in patients with symptomatic stenosis. However, no individual trail has been large enough to examine the effect of either treatment in any particular patient subgroup with any certainty.

Therefore in this meta-analysis the authors examined individual patient data (n=3433) from three randomised controlled trials; EVA-3S, SPACE, and the International Carotid Stenting Study (ICSS). The primary outcome measure was any stroke or death. Intention-to-treat analysis included all patients and outcome events occurring between randomisation and 120 days thereafter. Per-protocol analysis was restricted to patients receiving the allocated treatment and to events occurring within 30 days of treatment.

Intention-to-treat analysis revealed that, in the first 120 days after randomisation, any stroke or death occurred significantly more often in the carotid stenting group (8.9% vs 5.8%; p=0.0006). A difference in treatment effect was only noted in patients younger than 70 years, who had a lower risk of the primary outcome measure compared to those aged 70 years or older (12.0% vs 5.9%, p=0.005), suggesting carotid stenting was almost twice as risky in the elderly.

Conclusions

While this meta-analysis suggests that carotid stenting should be avoided in the elderly, it also shows that it may be as effective as carotid endarterectomy in younger patients.

▶ Carotid Stenting Trialists’ Collaboration. Short-term outcome after stenting versus endarterectomy for symptomatic carotid stenosis: a preplanned meta-analysis of individual patient data. Lancet 2010. doi:10.1016/S0140-6736(10)61009-4.