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Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): a randomised controlled trial with cost-effectiveness analysis.
Health Technol Assess. 2016 Mar; 20(20):1-94.HT

Abstract

BACKGROUND

Carotid artery stenting (CAS) is an alternative to carotid endarterectomy (CEA) for the treatment of carotid stenosis, but safety and long-term efficacy were uncertain.

OBJECTIVE

To compare the risks, benefits and cost-effectiveness of CAS versus CEA for symptomatic carotid stenosis.

DESIGN

International, multicentre, randomised controlled, open, prospective clinical trial.

SETTING

Hospitals at 50 centres worldwide.

PARTICIPANTS

Patients older than 40 years of age with symptomatic atheromatous carotid artery stenosis.

INTERVENTIONS

Patients were randomly allocated stenting or endarterectomy using a computerised service and followed for up to 10 years.

MAIN OUTCOME MEASURES

The primary outcome measure was the long-term rate of fatal or disabling stroke, analysed by intention to treat (ITT). Disability was assessed using the modified Rankin Scale (mRS). A cost-utility analysis estimating mean costs and quality-adjusted life-years (QALYs) was calculated over a 5-year time horizon.

RESULTS

A total of 1713 patients were randomised but three withdrew consent immediately, leaving 1710 for ITT analysis (853 were assigned to stenting and 857 were assigned to endarterectomy). The incidence of stroke, death or procedural myocardial infarction (MI) within 120 days of treatment was 8.5% in the CAS group versus 5.2% in the CEA group (72 vs. 44 events) [hazard ratio (HR) 1.69, 95% confidence interval (CI) 1.16 to 2.45; p = 0.006]. In the analysis restricted to patients who completed stenting, age independently predicted the risk of stroke, death or MI within 30 days of CAS (relative risk increase 1.17% per 5 years of age, 95% CI 1.01% to 1.37%). Use of an open-cell stent conferred higher risk than a closed-cell stent (relative risk 1.92, 95% CI 1.11 to 3.33), but use of a cerebral protection device did not modify the risk. CAS was associated with a higher risk of stroke in patients with an age-related white-matter changes score of 7 or more (HR 2.98, 95% CI 1.29 to 6.93; p = 0.011). After completion of follow-up with a median of 4.2 years, the number of patients with fatal or disabling stroke in the CAS and CEA groups (52 vs. 49), and the cumulative 5-year risk did not differ significantly (6.4% vs. 6.5%) (HR 1.06, 95% CI 0.72 to 1.57; p = 0.776). Stroke of any severity was more frequent in the CAS group (15.2% vs. 9.4% in the CEA group) (HR 1.712, 95% CI 1.280 to 2.300; p < 0.001). There was no significant difference in long-term rates of severe carotid restenosis or occlusion (10.8% in the CAS group vs. 8.6% in the CEA group) (HR 1.25, 95% CI 0.89 to 1.75; p = 0.20). There was no difference in the distribution of mRS scores at 1-year, 5-year or final follow-up. There were no differences in costs or QALYs between the treatments.

LIMITATIONS

Patients and investigators were not blinded to treatment allocation. Interventionists' experience of stenting was less than that of surgeons with endarterectomy. Data on costs of managing strokes were not collected.

CONCLUSIONS

The functional outcome after stenting is similar to endarterectomy, but stenting is associated with a small increase in the risk of non-disabling stroke. The choice between stenting and endarterectomy should take into account the procedural risks related to individual patient characteristics. Future studies should include measurement of cognitive function, assessment of carotid plaque morphology and identification of clinical characteristics that determine benefit from revascularisation.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN25337470.

FUNDING

This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 20. See the NIHR Journal Library website for further project information. Further funding was provided by the Medical Research Council, Stroke Association, Sanofi-Synthélabo and the European Union.

Authors+Show Affiliations

Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, London, UK.Department of Medical Statistics Unit, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK.Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, London, UK.Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, London, UK.Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, London, UK. Department of Neurology and Stroke Centre, University Hospital Basel, Basel University, Basel, Switzerland.Department of Applied Health Research, University College London, London, UK.Department of Applied Health Research, University College London, London, UK.Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, London, UK.

Pub Type(s)

Comparative Study
Journal Article
Multicenter Study
Randomized Controlled Trial
Research Support, Non-U.S. Gov't

Language

eng

PubMed ID

26979174

Citation

Featherstone, Roland L., et al. "Carotid Artery Stenting Compared With Endarterectomy in Patients With Symptomatic Carotid Stenosis (International Carotid Stenting Study): a Randomised Controlled Trial With Cost-effectiveness Analysis." Health Technology Assessment (Winchester, England), vol. 20, no. 20, 2016, pp. 1-94.
Featherstone RL, Dobson J, Ederle J, et al. Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): a randomised controlled trial with cost-effectiveness analysis. Health Technol Assess. 2016;20(20):1-94.
Featherstone, R. L., Dobson, J., Ederle, J., Doig, D., Bonati, L. H., Morris, S., Patel, N. V., & Brown, M. M. (2016). Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): a randomised controlled trial with cost-effectiveness analysis. Health Technology Assessment (Winchester, England), 20(20), 1-94. https://doi.org/10.3310/hta20200
Featherstone RL, et al. Carotid Artery Stenting Compared With Endarterectomy in Patients With Symptomatic Carotid Stenosis (International Carotid Stenting Study): a Randomised Controlled Trial With Cost-effectiveness Analysis. Health Technol Assess. 2016;20(20):1-94. PubMed PMID: 26979174.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): a randomised controlled trial with cost-effectiveness analysis. AU - Featherstone,Roland L, AU - Dobson,Joanna, AU - Ederle,Jörg, AU - Doig,David, AU - Bonati,Leo H, AU - Morris,Stephen, AU - Patel,Nishma V, AU - Brown,Martin M, PY - 2016/3/17/entrez PY - 2016/3/17/pubmed PY - 2016/12/28/medline SP - 1 EP - 94 JF - Health technology assessment (Winchester, England) JO - Health Technol Assess VL - 20 IS - 20 N2 - BACKGROUND: Carotid artery stenting (CAS) is an alternative to carotid endarterectomy (CEA) for the treatment of carotid stenosis, but safety and long-term efficacy were uncertain. OBJECTIVE: To compare the risks, benefits and cost-effectiveness of CAS versus CEA for symptomatic carotid stenosis. DESIGN: International, multicentre, randomised controlled, open, prospective clinical trial. SETTING: Hospitals at 50 centres worldwide. PARTICIPANTS: Patients older than 40 years of age with symptomatic atheromatous carotid artery stenosis. INTERVENTIONS: Patients were randomly allocated stenting or endarterectomy using a computerised service and followed for up to 10 years. MAIN OUTCOME MEASURES: The primary outcome measure was the long-term rate of fatal or disabling stroke, analysed by intention to treat (ITT). Disability was assessed using the modified Rankin Scale (mRS). A cost-utility analysis estimating mean costs and quality-adjusted life-years (QALYs) was calculated over a 5-year time horizon. RESULTS: A total of 1713 patients were randomised but three withdrew consent immediately, leaving 1710 for ITT analysis (853 were assigned to stenting and 857 were assigned to endarterectomy). The incidence of stroke, death or procedural myocardial infarction (MI) within 120 days of treatment was 8.5% in the CAS group versus 5.2% in the CEA group (72 vs. 44 events) [hazard ratio (HR) 1.69, 95% confidence interval (CI) 1.16 to 2.45; p = 0.006]. In the analysis restricted to patients who completed stenting, age independently predicted the risk of stroke, death or MI within 30 days of CAS (relative risk increase 1.17% per 5 years of age, 95% CI 1.01% to 1.37%). Use of an open-cell stent conferred higher risk than a closed-cell stent (relative risk 1.92, 95% CI 1.11 to 3.33), but use of a cerebral protection device did not modify the risk. CAS was associated with a higher risk of stroke in patients with an age-related white-matter changes score of 7 or more (HR 2.98, 95% CI 1.29 to 6.93; p = 0.011). After completion of follow-up with a median of 4.2 years, the number of patients with fatal or disabling stroke in the CAS and CEA groups (52 vs. 49), and the cumulative 5-year risk did not differ significantly (6.4% vs. 6.5%) (HR 1.06, 95% CI 0.72 to 1.57; p = 0.776). Stroke of any severity was more frequent in the CAS group (15.2% vs. 9.4% in the CEA group) (HR 1.712, 95% CI 1.280 to 2.300; p < 0.001). There was no significant difference in long-term rates of severe carotid restenosis or occlusion (10.8% in the CAS group vs. 8.6% in the CEA group) (HR 1.25, 95% CI 0.89 to 1.75; p = 0.20). There was no difference in the distribution of mRS scores at 1-year, 5-year or final follow-up. There were no differences in costs or QALYs between the treatments. LIMITATIONS: Patients and investigators were not blinded to treatment allocation. Interventionists' experience of stenting was less than that of surgeons with endarterectomy. Data on costs of managing strokes were not collected. CONCLUSIONS: The functional outcome after stenting is similar to endarterectomy, but stenting is associated with a small increase in the risk of non-disabling stroke. The choice between stenting and endarterectomy should take into account the procedural risks related to individual patient characteristics. Future studies should include measurement of cognitive function, assessment of carotid plaque morphology and identification of clinical characteristics that determine benefit from revascularisation. TRIAL REGISTRATION: Current Controlled Trials ISRCTN25337470. FUNDING: This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 20. See the NIHR Journal Library website for further project information. Further funding was provided by the Medical Research Council, Stroke Association, Sanofi-Synthélabo and the European Union. SN - 2046-4924 UR - https://www.unboundmedicine.com/medline/citation/26979174/Carotid_artery_stenting_compared_with_endarterectomy_in_patients_with_symptomatic_carotid_stenosis__International_Carotid_Stenting_Study_:_a_randomised_controlled_trial_with_cost_effectiveness_analysis_ L2 - https://doi.org/10.3310/hta20200 DB - PRIME DP - Unbound Medicine ER -