Fast track — ArticlesClinical and angiographic risk factors for stroke and death within 30 days after carotid endarterectomy and stent-protected angioplasty: a subanalysis of the SPACE study
Introduction
Extracranial stenosis of the internal carotid artery is an important cause of ischaemic stroke, particularly in patients with recent ischaemic ocular symptoms, transient ischaemic attack (TIA), or stroke. Available treatments include carotid artery stenting (CAS), carotid endarterectomy (CEA), and medical therapy (treatment of vascular risk factors and follow-up of the stenosis with ultrasound). The risk of stroke and death resulting from CEA has been shown to depend on clinical indication.1 CAS and CEA are based on different treatment principles, which might result in different risk characteristics in patients who undergo these procedures. The efficacy of CAS might best be tested in a population for which CEA seems to have a high risk,2 because CAS is potentially less invasive and might have a lower complication rate in medically compromised, high-risk patients than does CEA. Improved assignment of patients with carotid stenosis to each procedure, by the identification of subgroups for treatment with CEA or CAS on the basis of simple variables, might allow the overall risk to be reduced.
The Stent-Protected Angioplasty versus Carotid Endarterectomy in Symptomatic Patients (SPACE) trial was a randomised controlled trial of CEA versus CAS for symptomatic carotid stenosis.3 On the basis of data from this trial, we aimed to analyse the risks of adverse events for these treatments separately. We postulated that complications after CEA and CAS would be associated with different risk factors.
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Patients and procedures
Patients were eligible for SPACE if they had amaurosis fugax, hemispherical TIA, or completed stroke in the previous 180 days and had stenosis of the ipsilateral carotid artery that was moderate to severe—ie, 50% or more according to criteria from the North American Symptomatic Carotid Endarterectomy Trial (NASCET),4 or 70% or more according to criteria from the European Carotid Surgery Trial (ECST).5 Further inclusion and exclusion criteria have been specified previously.3 All patients
Results
The intention-to-treat analysis (table 1) included data from 1196 patients, 607 randomly assigned to CAS and 589 randomly assigned to CEA. These numbers differ from those in the previous analysis3 because 14 more patients were assigned to treatment between the interim analysis and the end of the trial, and six patients assigned to CAS and 12 assigned to CEA withdrew consent before therapy. The per-protocol analysis (table 2) included data from 573 (94%) patients in the CAS group and 563 (96%)
Discussion
Bond and colleagues1 reported associations of factors with a higher than average risk from CEA in a combined analysis of data from NASCET and ECST. Risk was higher when the qualifying event was TIA than if it was amaurosis fugax,1 and was higher when the contralateral internal carotid artery was occluded than when it was not.9 For CAS, risk factors for periprocedural complications are less well defined. Trials presented at scientific meetings include Acculink for Revascularization of Carotids
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