Editor's Choice - Stroke and Death Following Carotid Endarterectomy or Carotid Artery Stenting: A Ten Year Nationwide Study in France

Abstract

Objective: This retrospective, nationwide cohort study aimed to compare peri-procedural stroke or death within 30 days of the procedure (PPSD30) in patients who underwent carotid endarterectomy (CEA) or carotid stenting (CAS).

Methods: This retrospective cohort study used data from the French hospital database PMSI. All patients who underwent CEA or CAS between 2010 and 2019 in France were included. Information on individual patients and hospital characteristics was retrieved. A random effects logistic regression model compared the occurrence of PPSD30 after CEA or CAS. High surgical risk was accounted for by using propensity score matching and adjusted for patient and hospital characteristics. Analyses were also stratified to consider symptomatic and asymptomatic patients separately.

Results: Between 2010 and 2019, 164 248 patients underwent a carotid artery procedure in France: 156 561 CEA and 7 687 CAS (including about 25% asymptomatic women and 40% high risk patients). The PPSD30 rate was 1.5% overall (n = 2 514 patients) (1.5% after CEA vs. 2.4% after CAS), 1.3% in asymptomatic patients (1.2% after CEA vs. 1.8% after CAS), and 3.3% in symptomatic patients (3.1% after CEA vs. 6.5% after CAS). After matching and adjustment, the risk of PPSD30 was statistically significantly greater in patients who underwent CAS than in patients who underwent CEA (adjusted OR [aOR] 1.4, 95% confidence interval [CI] 1.1 - 1.8 overall; aOR 1.4, 95% CI 1.1 - 1.8 in asymptomatic patients; and aOR 2.7, 95% CI 1.8 - 4.0 in symptomatic patients).

Conclusion: This nationwide real life study showed that CEA performed better than CAS, more markedly in symptomatic patients, but also in asymptomatic patients. Moreover, many patients received procedures that were more likely to be harmful than beneficial according to conclusions from past randomised trials (i.e., all asymptomatic women, all high surgical risk patients, and all who had undergone CAS).

Keywords: Carotid artery stenosis; Carotid artery stenting; Carotid endarterectomy; In hospital mortality; Ischaemic stroke.