Length of carotid stenosis predicts peri-procedural stroke or death and restenosis in patients randomized to endovascular treatment or endarterectomy

L.H. Bonati, J. Ederle, J. Dobson, S. Engelter, R.L. Featherstone, P.A. Gaines, J.D. Beard, G.S. Venables, H.S. Markus, A. Clifton, P. Sandercock, M.M. Brown, J.M. Bland, T. Buckenham, P.A.G. Sandercock, R.S. Taylor, G. Tognoni, C.P. Warlow, T. Bleakley, D. ColquhounL. Coward, F. Crawley, P. Dobinson, R. Featherstone, S. Holder, H. Markus, D.J.H. Mccabe, A. Pereira, J. Rogers, L. Silver, J. Burrett, J. Crowther, M. Dobson, B. Hafner, J. Heineman, C. Hope, S. Knight, A. Naughten, A. Radley, S. Richards, D. Smith, S. Wenzel, M. Harrison, J. Ferro, J. Beard, C.F. Bladin, G.A. Donnan, G. Fell, G. Fitt, J. Royle, S. Davis, R. Gerraty, P. Mitchell, M.A. Goodman, Graeme Hankey, M.S. Khangure, M.M. Lawrence-Brown, J. Linto, Will Mcauliffe, F.J. Prendergast, K. Siennarine, E.G. Stewart-Wynne, S. Grahovac, W. Morrish, N. Pageau, C. E Pringle, D.M. Richard, J. Malms, L. Reiher, M. Siebler, G. Belloni, M. Porta, A. Chamorro, N. Vila, V. Riambau, F. Vazquez, F. Boza, J.L. Garcia Rodríguez, A. Gil Peralta, A. González, J.R. González Marcos, A. Mayol Deya, J. Rauno, E.C. Kirsch, P.A. Lyrer, J.A. Rem, J. Bogousslavsky, A. Uske, T.J. Cleveland, C. Doyle, A. Sivaguru, P.W. Leopold, T. Loosemore, T.P. Enevoldson, G. Gilling-Smith, P. Harris, T. Nixon, P. Baskerville, T. Cox, S. Fraser, M. Jeffrey, J. Molloy, P. Butler, J. Dick, F. Frankel, A. Bradbury, D. Collie, J.A. Murie, C.V. Ruckley, D. Schultz, R.J. Sellar, J. Wardlaw, R.J. Ashleigh, C.N. Mccollum, P. O'Neill, A. Gholkar, A.D. Mendelow, T.J. Walls, H. Angus-Leppan, S. Halpin, J. Hughes, I. Lane, M. Wiles, A.M. Wood, P.A. Birch, J.J. Earnshaw, G.N. Fuller, B. Heather, K. Poskitt, A.J. Tottle, D.T. Hope, D. Jefferson, N. Mcconachie, M. Duddy, M.T.E. Heafield, R.K. Vohra

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    Abstract



    Background


    The anatomy of carotid stenosis may influence the outcome of endovascular treatment or carotid endarterectomy. Whether anatomy favors one treatment over the other in terms of safety or efficacy has not been investigated in randomized trials.



    Methods


    In 414 patients with mostly symptomatic carotid stenosis randomized to endovascular treatment (angioplasty or stenting; n = 213) or carotid endarterectomy (n = 211) in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS), the degree and length of stenosis and plaque surface irregularity were assessed on baseline intraarterial angiography. Outcome measures were stroke or death occurring between randomization and 30 days after treatment, and ipsilateral stroke and restenosis ⩾50% during follow-up.



    Results


    Carotid stenosis longer than 0·65 times the common carotid artery diameter was associated with increased risk of peri-procedural stroke or death after both endovascular treatment [odds ratio 2·79 (1·17–6·65), P = 0·02] and carotid endarterectomy [2·43 (1·03–5·73), P = 0·04], and with increased long-term risk of restenosis in endovascular treatment [hazard ratio 1·68 (1·12–2·53), P = 0·01]. The excess in restenosis after endovascular treatment compared with carotid endarterectomy was significantly greater in patients with long stenosis than with short stenosis at baseline (interaction P = 0·003). Results remained significant after multivariate adjustment. No associations were found for degree of stenosis and plaque surface.



    Conclusions


    Increasing stenosis length is an independent risk factor for peri-procedural stroke or death in endovascular treatment and carotid endarterectomy, without favoring one treatment over the other. However, the excess restenosis rate after endovascular treatment compared with carotid endarterectomy increases with longer stenosis at baseline. Stenosis length merits further investigation in carotid revascularisation trials.
    Original languageEnglish
    Pages (from-to)297-305
    JournalInternational Journal of Stroke
    Volume9
    Issue number3
    DOIs
    Publication statusPublished - Apr 2014

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