Risk of Stroke before Revascularisation in Patients with Symptomatic Carotid Stenosis: A Pooled Analysis of Randomised Controlled Trials - Archive ouverte HAL Access content directly
Journal Articles European Journal of Vascular and Endovascular Surgery Year : 2021

Risk of Stroke before Revascularisation in Patients with Symptomatic Carotid Stenosis: A Pooled Analysis of Randomised Controlled Trials

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Stefanie von Felten
  • Function : Author
Andrea Wiencierz
  • Function : Author
Olav Jansen
  • Function : Author
George Howard
  • Function : Author
Jeroen Hendrikse
  • Function : Author
Alison Halliday
  • Function : Author
Gustav Fraedrich
  • Function : Author
Hans-Henning Eckstein
  • Function : Author
Richard Bulbulia
  • Function : Author
Jean-Pierre Becquemin
  • Function : Author
Ale Algra
  • Function : Author
Peter Rothwell
  • Function : Author
Peter Ringleb
  • Function : Author
Jean-Louis Mas
  • Function : Author
Martin Brown
  • Function : Author
Thomas Brott
  • Function : Author

Abstract

Objective: Current guidelines recommending rapid revascularisation of symptomatic carotid stenosis are largely based on data from clinical trials performed at a time when best medical therapy was potentially less effective than today. The risk of stroke and its predictors among patients with symptomatic carotid stenosis awaiting revascularisation in recent randomised controlled trials (RCTs) and in medical arms of earlier RCTs was assessed. Methods: The pooled data of individual patients with symptomatic carotid stenosis randomised to stenting (CAS) or endarterectomy (CEA) in four recent RCTs, and of patients randomised to medical therapy in three earlier RCTs comparing CEA vs. medical therapy, were compared. The primary outcome event was any stroke occurring between randomisation and treatment by CAS or CEA, or within 120 days after randomisation. Results: A total of 4 754 patients from recent trials and 1 227 from earlier trials were included. In recent trials, patients were randomised a median of 18 (IQR 7, 50) days after the qualifying event (QE). Twenty-three suffered a stroke while waiting for revascularisation (cumulative 120 day risk 1.97%, 95% confidence interval [CI] 0.75 - 3.17). Shorter time from QE until randomisation increased stroke risk after randomisation (χ2 = 6.58, p = .011). Sixty-one patients had a stroke within 120 days of randomisation in the medical arms of earlier trials (cumulative risk 5%, 95% CI 3.8 - 6.2). Stroke risk was lower in recent than earlier trials when adjusted for time between QE and randomisation, age, severity of QE, and degree of carotid stenosis (HR 0.47, 95% CI 0.25 - 0.88, p = .019). Conclusion: Patients with symptomatic carotid stenosis enrolled in recent large RCTs had a lower risk of stroke after randomisation than historical controls. The added benefit of carotid revascularisation to modern medical care needs to be revisited in future studies. Until then, adhering to current recommendations for early revascularisation of patients with symptomatic carotid stenosis considered to require invasive treatment is advisable.

Dates and versions

hal-03258509 , version 1 (11-06-2021)

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Urs Fisch, Stefanie von Felten, Andrea Wiencierz, Olav Jansen, George Howard, et al.. Risk of Stroke before Revascularisation in Patients with Symptomatic Carotid Stenosis: A Pooled Analysis of Randomised Controlled Trials. European Journal of Vascular and Endovascular Surgery, 2021, ⟨10.1016/j.ejvs.2021.02.024⟩. ⟨hal-03258509⟩
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