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  • Review Article
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Stenting for carotid artery stenosis

Abstract

Stenting has increasingly been used for the treatment of carotid artery stenosis, although it is still unknown whether it is as safe and successful as carotid endarterectomy. Several studies have been published, and the preliminary results have been variable, with evidence both in favor of and against this procedure. In the past few months, primary outcome data have been published from two large European randomized multicenter trials (SPACE and EVA-3S). So far, both of these trials have evaluated whether carotid stenting shows noninferiority compared with carotid endarterectomy in symptomatic patients with severe carotid disease over a period of 30 days after intervention. In this Review, we summarize current knowledge on effectiveness of both procedures, and provide an updated meta-analysis based on randomized trial data, including SPACE and EVA-3S. This meta-analysis shows a lower procedure-related rate of stroke or death in surgically treated patients. The long-term risk/benefit ratio of carotid stenting remains to be determined. Two other randomized multicenter trials—ICSS and CREST—are ongoing. With an intended sample size of up to 7,000 patients, future meta-analyses will allow more-accurate treatment recommendations and subgroup analysis.

Key Points

  • Carotid artery stenting has become the endovascular technique of choice for treatment of carotid artery stenosis, but there is ongoing controversy as to whether or not this procedure is as safe and effective as carotid endarterectomy

  • The first results of two large randomized multicenter trials evaluating the noninferiority of endovascular treatment compared with endarterectomy in symptomatic patients—SPACE and EVA-3S—were recently published

  • The 30-day results of the SPACE trial showed similar rates of the primary end point “ipsilateral ischemic stroke or death” for the two procedures, whereas in the EVA-3S study a significantly higher periprocedural risk was observed in the stenting group

  • An updated meta-analysis of seven randomized trials that compared the effectiveness of carotid endarterectomy and stenting, mostly in symptomatic patients, reveals a significant disadvantage of endovascular treatment for the end point “any stroke and death within 30 days after treatment”, but the risk of the end point “disabling stroke and death” was similar in the two groups

  • Patients enrolled and treated in the SPACE and EVA-3S trial are currently undergoing follow-up, and the first results of two ongoing trials, the ICSS and CREST, are expected in 2008

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Figure 1: Summary of randomized trials comparing carotid artery stenting (CAS) and carotid endarterectomy (CEA) for the treatment of severe carotid artery stenosis
Figure 2: Meta-analysis of randomized trials comparing carotid artery stenting (CAS) and carotid endarterectomy (CEA) for the treatment of severe carotid artery stenosis

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Correspondence to Michael G Hennerici.

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Competing interests

PA Ringleb, W Hacke and M Hennerici were involved in the SPACE trial and have received fees from Sanofi-Aventis. J-L Mas is the Principal Investigator of the EVA-3S study, which was supported by a grant from the Programme Hospitalier de Recherche Clinique of the French Ministry of Health (AOM 97066), Assistance Publique–Hôpitaux de Paris. R Kern declared in has no competing interests.

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Kern, R., Ringleb, P., Hacke, W. et al. Stenting for carotid artery stenosis. Nat Rev Neurol 3, 212–220 (2007). https://doi.org/10.1038/ncpneuro0470

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