title: Outcomes of carotid endarterectomy versus stenting in comparable medical risk patients.
abstract: OBJECTIVE
  In medically high-risk patients the choice between carotid artery stenting (CAS) and carotid endarterectomy (CEA) can be difficult. The purpose of this study was to compare risk-stratified outcomes of CAS and CEA.
  
  
  METHODS
  Patients who underwent isolated primary CEA (n = 11,336) or primary CAS (n = 544) at 29 centers in the Vascular Study Group of New England were analyzed (2003-2013); patients with previous ipsilateral CEA or CAS, or concomitant coronary artery bypass graft were excluded. A medical risk score based on predicted 5-year mortality was developed for each patient using a Cox proportional hazards model. Patients in the highest risk score quartile were termed high-risk (vs normal-risk for the other three quartiles). Medically high-risk patients had a 5-year survival of 65% and comprised 23% of CEA and 25% of CAS patients. Risk-stratified outcomes were compared within neurologically symptomatic and asymptomatic patients.
  
  
  RESULTS
  Among asymptomatic patients, rates of in-hospital stroke and/or death were not different between CAS and CEA in normal and high-risk cohorts, ranging from 0.7% in normal-risk CEA patients to 1.6% in high-risk CAS patients. In symptomatic patients, significantly worse outcomes were seen with CAS compared with CEA in normal-risk and high-risk patients. Normal-risk symptomatic patients had a stroke or death rate of 1.3% with CEA, but 5.2% with CAS (P < .01). In high-risk symptomatic patients, the stroke or death rate was 1.5% with CEA and 9.3% with CAS (P < .01). No significant differences were seen between asymptomatic CEA and CAS within risk strata across secondary outcome measures of stroke, death, or myocardial infarction, and ipsilateral stroke, major stroke, or death. However, symptomatic high-risk CAS patients had significantly greater rates of all secondary outcomes compared with CEA except death, and symptomatic normal-risk CAS patients had only significantly greater rates of death and stroke, death, or myocardial infarction.
  
  
  CONCLUSIONS
  In the Vascular Study Group of New England, asymptomatic normal- and high-risk patients do equally well after CEA or CAS. However, normal- and high-risk symptomatic patients have substantially worse outcomes with CAS compared with CEA. High medical risk alone might be an insufficient indication for CAS in symptomatic patients.
authors: Section of Vascular Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH. Electronic address: spangler@alum.mit.edu.
authors: Emily L
authors: EL
authors: Spangler
authors: Section of Vascular Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH.
authors: Philip P
authors: PP
authors: Goodney
authors: Division of Vascular and Endovascular Surgery, University of Massachusetts-Memorial Medical Center, Worcester, Mass.
authors: Andres
authors: A
authors: Schanzer
authors: Section of Vascular Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH.
authors: David H
authors: DH
authors: Stone
authors: Department of Vascular and Endovascular Surgery, Beth-Israel Deaconess Medical Center, Boston, Mass.
authors: Marc L
authors: ML
authors: Schermerhorn
authors: Section of Vascular Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH.
authors: Richard J
authors: RJ
authors: Powell
authors: Section of Vascular Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH.
authors: Jack L
authors: JL
authors: Cronenwett
authors: Section of Vascular Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH.
authors: Brian W
authors: BW
authors: Nolan
mesh_terms: D017130:Angioplasty / Q000009:adverse effects / Q000295:instrumentation* / Q000401:mortality; D058070:Asymptomatic Diseases; D002340:Carotid Artery Diseases / Q000150:complications / Q000175:diagnosis / Q000401:mortality / Q000601:surgery / Q000628:therapy*; D016894:Endarterectomy, Carotid / Q000009:adverse effects / Q000401:mortality; D017052:Hospital Mortality; D006801:Humans; D009203:Myocardial Infarction / Q000209:etiology / Q000401:mortality; D009511:New England; D016016:Proportional Hazards Models; D012042:Registries; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D015607:Stents; D020521:Stroke / Q000209:etiology / Q000401:mortality; D013997:Time Factors; D016896:Treatment Outcome