title: The risk of carotid artery stenting compared with carotid endarterectomy is greatest in patients treated within 7 days of symptoms.
abstract: OBJECTIVE
  Among patients with symptomatic carotid artery stenosis, carotid artery stenting (CAS) is associated with a higher risk of periprocedural stroke or death than carotid endarterectomy (CEA). Uncertainty remains whether the balance of risk changes with time since the most recent ischemic event.
  
  
  METHODS
  We investigated the association of time between the qualifying ischemic event and treatment (0-7 days, 8-14 days, and >14 days) with the risk of stroke or death within 30 days after CAS or CEA in a pooled analysis of data from individual patients randomized in the Endarterectomy vs Angioplasty in Patients with Symptomatic Severe Carotid Stenosis (EVA-3S) trial, the Stent-Protected Angioplasty versus Carotid Endarterectomy (SPACE) trial, and the International Carotid Stenting Study (ICSS). Data were analyzed with a fixed-effect binomial regression model adjusted for source trial.
  
  
  RESULTS
  Information on time of qualifying event was available for 2839 patients. In the first 30 days after intervention, any stroke or death occurred significantly more often in the CAS group (110/1434 [7.7%]) compared with the CEA group (54/1405 [3.8%]; crude risk ratio, 2.0; 95% confidence interval, 1.5-2.7). Patients undergoing CEA within the first 7 days of the qualifying event had the lowest periprocedural stroke or death rate (3/106 [2.8%]). Patients treated with CAS in the same period had a 9.4% risk of periprocedural stroke or death (13/138; risk ratio CAS vs CEA: 3.4; 95% confidence interval, 1.01-11.8; adjusted for age, sex, and type of qualifying event). Patients treated between 8 and 14 days showed a periprocedural stroke or death rate of 3.4% (7/208) and 8.1% (19/234), respectively, for CEA and CAS. The latest treatment group had 4% complications in the CEA group (44/1091) and 7.3% in the CAS group (78/1062).
  
  
  CONCLUSIONS
  The increase in risk of CAS compared with CEA appears to be greatest in patients treated within 7 days of symptoms. Early surgery might remain most effective in stroke prevention in patients with symptomatic carotid artery stenosis.
authors.affiliation: Department of Vascular Surgery, Innsbruck Medical University, Innsbruck, Austria.
authors.forename: Barbara
authors.initials: B
authors.lastname: Rantner
authors.forename: Georg
authors.initials: G
authors.lastname: Goebel
authors.forename: Leo H
authors.initials: LH
authors.lastname: Bonati
authors.forename: Peter A
authors.initials: PA
authors.lastname: Ringleb
authors.forename: Jean-Louis
authors.initials: JL
authors.lastname: Mas
authors.forename: Gustav
authors.initials: G
authors.lastname: Fraedrich
mesh_terms: D000368:Aged; D017130:Angioplasty / Q000009:adverse effects / Q000295:instrumentation* / Q000401:mortality; D016893:Carotid Stenosis / Q000150:complications / Q000401:mortality / Q000601:surgery / Q000628:therapy*; D016894:Endarterectomy, Carotid / Q000009:adverse effects / Q000401:mortality; D005060:Europe; D005260:Female; D006801:Humans; D002546:Ischemic Attack, Transient / Q000209:etiology / Q000401:mortality / Q000517:prevention & control; D008297:Male; D008875:Middle Aged; D015337:Multicenter Studies as Topic; D016017:Odds Ratio; D016032:Randomized Controlled Trials as Topic; D018570:Risk Assessment; D012307:Risk Factors; D015607:Stents; D020521:Stroke / Q000209:etiology / Q000401:mortality / Q000517:prevention & control; D013997:Time Factors; D061665:Time-to-Treatment; D016896:Treatment Outcome