CAROTID ENDARTERECTOMY VERSUS STENTING: A DECISION ANALYSIS

Purpose: More than 150,000 patients undergo carotid endarterectomy (CEA) or carotid artery stenting (CAS) annually for the prevention of ischemic stroke in the United States alone. The benefit of CEA relative to CAS in stroke prevention is limited by the elevated risk of myocardial infarction following CEA. In light of this consideration, a decision analysis model was used to evaluate expected outcomes from these two treatment strategies.

Method: Data from meta-analyses and systematic reviews of the literature were used to define event rates of stroke, myocardial infarction and death. The periprocedural period decision analytic model was stratified for age, gender and symptom status. Sensitivity analysis was performed to evaluate the influence of ranges of reported event rates on the relative efficacy of the two treatment strategies. Quality-adjusted life years was used as a measure of efficacy.

Result: Over the course of a 4-year study period CEA was the preferred treatment strategy resulting in a quality-adjusted life expectancy gain of 22 days. Sensitivity analyses demonstrated CEA as the preferred strategy when periprocedural rates of stroke associated with CAS and CEA were greater 2.7% and less than 6.0%, respectively. Subgroup analysis revealed the short-term periprocedural benefit of CEA relative to CAS to be most pronounced in patients who are greater than 70 years of age (15 days). The advantage of CEA was marginal among male, female and symptomatic patients (7, 4, and 4 days, respectively) while no treatment strategy was dominant among asymptomatic patients and those under 70 years of age.

Conclusion: In a decision analysis model of the treatment of carotid stenosis CEA was the preferred intervention particularly among patients greater than 70 years of age. The benefit of CEA is dependent on periprocedural rates of stroke being below 6.0%. In centers achieving CAS periprocedural stroke rates less than 2.7%, CAS should be performed.