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Ann Surg. 2018 Aug;268(2):364-373. doi: 10.1097/SLA.0000000000002301.

Long-term Outcomes of Carotid Endarterectomy Versus Stenting in a Multicenter Population-based Canadian Study.

Hussain MA1,2, Mamdani M3,4,5,6,7, Tu JV8,4,6,9, Saposnik G10,3,8,4,6, Aljabri B1,7,11, Bhatt DL12, Verma S13,3,2,7, Al-Omran M1,3,2,7,11.

Author information

1
Division of Vascular Surgery, St. Michael's Hospital, Toronto, Ontario, Canada.
2
Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
3
Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada.
4
Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.
5
Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada.
6
Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
7
King Saud University-Li Ka Shing Collaborative Research Program, King Saud University, Riyadh, Kingdom of Saudi Arabia.
8
Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
9
Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
10
Division of Neurology, St. Michael's Hospital, Toronto, Ontario, Canada.
11
Department of Surgery, King Saud University, Riyadh, Kingdom of Saudi Arabia.
12
Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA.
13
Division of Cardiac Surgery, St. Michael's Hospital, Toronto, Ontario, Canada.

Abstract

OBJECTIVE:

To compare the long-term outcomes of patients treated with carotid endarterectomy and carotid-artery stenting.

BACKGROUND:

Evidence for the long-term safety and efficacy of carotid-artery stenting compared with endarterectomy is accumulating from randomized trials. However, comparative data on the long-term outcomes of carotid revascularization strategies in real world practice are lacking.

METHODS:

We conducted a population-based, multicenter, observational cohort study using validated linked databases from Ontario, Canada. We identified all individuals treated with carotid endarterectomy and stenting (2002-2014), and followed them up to 2015. We compared long-term (up to 13 years) and 30-day outcomes of each strategy using multilevel multivariable Cox proportional-hazards models, and conducted confirmatory analyses using propensity-score matching methods.

RESULTS:

In all, 15,525 patients received carotid-artery revascularization. Rate of the primary composite outcome of 30-day death, stroke, or myocardial infarction plus any stroke during 13-year follow-up was higher with stenting (16.3%) compared with endarterectomy (9.7%) [adjusted hazard ratio (HR) 1.57, 95% confidence interval (CI) 1.43-1.73, P < 0.001). The increased risk with stenting was observed regardless of age, sex, intervention year, carotid-artery symptoms, or diabetes. The primary outcome was driven by higher rates of 30-day stroke (adjusted HR 1.59, 95% CI 1.29-1.95), 30-day death (adjusted HR 2.62, 95% CI 2.20-3.13), and long-term stroke >30 days after the procedure (adjusted HR 1.47, 95% CI 1.36-1.59) with stenting; 30-day myocardial infarction was lower with stenting (adjusted HR 0.70, 95% CI 0.57-0.86). These results were confirmed with 1:2 propensity-score matching (HR for primary composite outcome with stenting 1.55, 95% CI 1.31-1.83, P < 0.001).

CONCLUSIONS:

Compared with carotid endarterectomy, stenting was associated with an early and sustained approximately 55% increased hazard for major adverse events over long-term follow-up. Although nonrandomized, these results raise potential concerns about the interchangeability of carotid endarterectomy and stenting in the context of actual clinical practice.

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