ICSS long-term data shows carotid stenting as good as endarterectomy for preventing fatal and disabling strokes

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The International Carotid Stenting Study (ICSS) randomised trial has reported the long-term outcomes after stenting versus endarterectomy for treatment of symptomatic carotid stenosis in The Lancet, online ahead of print, on 14 October.

“Stenting is an alternative to endarterectomy for treatment of carotid artery stenosis, but long-term efficacy is uncertain,” the authors wrote in the background to the trial. Their findings conclude that long-term functional outcome and risk of fatal or disabling stroke are similar for stenting and endarterectomy for symptomatic carotid stenosis.

The study followed 1,713 patients with carotid artery disease, of whom 855 were assigned to stenting and 858 to endarterectomy, for up to 10 years. The median follow-up was 4.2 years. Both techniques were found to be equally good at preventing fatal and disabling strokes, but patients who underwent stenting were slightly more likely to have minor strokes without long-term effects. The risk of any stroke in five years was 15.2% in the stenting group compared to 9.4% in the endarterectomy group, but the additional strokes were minor and had no impact on long-term quality of life.

The paper was authored researchers from University College London (UCL), Basel University, Switzerland, the London School of Hygiene & Tropical Medicine, the University Medical Center Utrecht, Netherlands, Sheffield Teaching Hospitals NHS Foundation Trust, and Newcastle University.

“At the moment, stenting is not widely used in the UK due to historical uncertainty over its long-term effectiveness,” said study leader Martin Brown from the UCL Institute of Neurology. “However, we have now shown that stenting is just as good as endarterectomy for preventing fatal and disabling strokes. We have also shown that the risk of stroke during the procedure is no higher for stenting than for endarterectomy in younger patients. The risks of each procedure are different and will vary depending on the patient, but stenting should be offered as an option to many more patients under the age of 70.

“One of the issues is that there are not many centres in this country that currently offer stenting as an option so the patient choice is not there. Now that we know stenting is effective in the long-term, more staff should be trained to carry out the procedure and gain experience. Otherwise there is a vicious cycle where nobody at a centre has stenting experience so patients are only offered endarterectomy and staff cannot learn or observe the procedure. In other countries, stenting is more widespread and the safety of the procedure improves as staff gain experience.”

 

The authors wrote in The Lancet: “Overall we found that stenting and endarterectomy are durable procedures that are equally effective in preventing severe strokes that lead to disability or death. Stenting has the disadvantage of causing more minor non-disabling strokes in the procedural period and possibly in the long term. This feature, however, must be weighed against the increased risk of procedural myocardial infarction, cranial nerve palsy, and access-site haematoma associated with endarterectomy. The modified Rankin scale scores suggested similar short-term and long-term functional outcomes with the two treatments. The choice between stenting and endarterectomy should take into account the different procedure-related risks in line with other characteristics of individual patients.”

Shamim Quadir, research communications manager at the Stroke Association said: “These latest research findings suggest that overall, stenting is just as safe, and equally effective for the long-term prevention of fatal and disabling strokes. Both procedures carry their own risks, and these will need to be considered for each individual patient. This research provides a vital step in providing another viable option which will help people significantly reduce their stroke risk.”