Durability of Stroke Prevention with Carotid Endarterectomy and Carotid Stenting

Background: Carotid artery stenting remains an effective alternative to carotid endarterectomy for stroke prevention; however, the long-term durability of carotid artery stenting remains poorly defined. We performed a 10-year “real-world” comparative analysis of carotid endarterectomy and carotid artery stenting to help evaluate the success of these procedures in preventing late ischemic stroke events. Methods: This was a single-center retrospective review of 996 patients (symptomatic and asymptomatic) treated with carotid endarterectomy or carotid artery stenting from January 2001 through December 2011 at a tertiary academic medical center. All-cause death, stroke, and myocardial infarction event rates were analyzed using log-rank analysis. Results: Among the 996 patients treated with carotid endarterectomy (n = 787) or carotid artery stenting (n = 209), the 30-day, 1-year, 5-year, and 10-year survival rates for carotid endarterectomy patients were 99.1%, 95.3%, 77.9%, and 54.8%; carotid artery stenting rates were 99.5%, 96.2%, 67.8%, and 40.2%, respectively (P = .005, at 10 years). There was no significant difference in early stroke rates or myocardial infarction rates between the groups. Subgroup analysis comparing symptomatic status demonstrated no statistically significant differences in overall survival, stroke, or myocardial infarction rates at 10 years. In addition to reduced long-term overall survival, carotid artery stenting patients had a higher long-term restenosis rate as compared to carotid endarterectomy (6.3% vs 2.8%, P < .0001) and reduced restenosis-free survival (P = .01). Conclusions: Early death, stroke, and myocardial infarction rates are comparable after carotid endarterectomy and carotid artery stenting. Carotid artery stenting is an effective means of preventing stroke among patients with carotid artery stenosis. Symptomatic status does not seem to affect rates of stroke, myocardial infarction, or death. Carotid endarterectomy continues to be the preferred long-term solution for extracranial carotid artery occlusive disease as it is associated with better long-term survival and lower restenosis rates.