Carotid endarterectomy and carotid artery stenting: changing paradigm during 10 years in a high-volume centre

• Published in: Acta neurochirurgica Vol. 156; no. 9; pp. 1705 - 1712
• Main Authors: Bradac, O., Mohapl, M., Kramar, F., Netuka, D., Ostry, S., Charvat, F., Lacman, J., Benes, V.
• Format: Journal Article
• Language: English
• Published: Vienna Springer Vienna 01-09-2014; Springer Nature B.V
• Subjects: Activities of Daily Living - classification; Aged; Aged, 80 and over; Carotid Stenosis - mortality; Carotid Stenosis - therapy; Clinical Article - Vascular; Endarterectomy, Carotid - methods; Endarterectomy, Carotid - trends; Female; Forecasting; Hospitals, High-Volume; Humans; Interventional Radiology; Ischemic Attack, Transient - prevention & control; Male; Medicine; Medicine & Public Health; Middle Aged; Minimally Invasive Surgery; Neurology; Neuroradiology; Neurosurgery; Retrospective Studies; Stents - adverse effects; Stroke - prevention & control; Surgical Orthopedics; Survival Analysis; Treatment Outcome; Complication; Stroke; Carotid endarterectomy; Carotid artery stenting; Outcome
• ISSN: 0001-6268; 0942-0940
• DOI: 10.1007/s00701-014-2166-x

Background
We analysed the results of internal carotid artery (ICA) stenosis treatment at our institution over the last 10 years according to treatment modalities (carotid endarterectomy [CEA] vs carotid artery stenting [CAS]). Furthermore, we compared our results of treatment prior to the EVA-3S study being implemented into our practice (2003–2007) and after that (2008–2012).
Method
During the years 2003–2012, a total of 1,471 procedures were performed for ICA stenosis. CEA was done in 815 cases and CAS in 656 cases. The primary outcome was disabling stroke (mRS > 2) or myocardial infarction (MI) within 30 days after treatment. Secondary outcomes were frequency of transient ischaemic attacks (TIAs), minor strokes (stroke without impaired activities of daily living [ADL]) and any other significant complication. Comparisons of the results before and after 2008 were performed.
Results
Major mortality and morbidity were divided according to treatment groups; reached 1.0 % in the CEA group and 3.0 % in the CAS group,
p
 = 0.004. Minor stroke was recorded at 1.8 % and 2.7 % in the CEA and CAS,
p
 = 0.245. TIAs in 1.0 % (CEA) and 4.7 % (CAS),
p
 < 0.001. Any complication in 11.9 % (CEA) and 13.3 % (CAS),
p
 = 0.401. In the overall results (i.e. CEA and CAS together), we found in 2008–2012 a decrease of incidence of TIAs (from 30/840 to 9/631,
p
 = 0.011) and any complications (from 120/840 to 64/631,
p
 = 0.017).
Conclusions
CEA performed in a high-volume centre is a safe procedure in properly indicated patients. In all subgroup analyses, CEA fared better than or at least of equal benefit as CAS. Since 2008, the frequency of TIAs and other complications decreased significantly. This study supports an idea of CEA being the first choice of treatment and CAS being reserved for strictly selected cases, such as re-stenosis after a previous carotid procedure, carotid dissection, ICA stenosis after radiotherapy, previous major neck surgery, contralateral cranial nerve palsy or tandem stenosis.