Emmanuel Touzé1, Ludovic Trinquart, Rui Felgueiras, Kittipan Rerkasem, Leo H Bonati, Gayané Meliksetyan, Peter A Ringleb, Jean-Louis Mas, Martin M Brown, Peter M Rothwell. 1. From the Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S894, Service de Neurologie, Hôpital Sainte-Anne, Paris, France (E.T., G.M., J.-L.M.); Université de Caen Basse Normandie, INSERM UMR-S U919, Service de Neurologie, CHU Côte de Nacre, Caen, France (E.T.); French Cochrane Centre, Université Paris Descartes, Sorbonne Paris Cité, INSERM U738, Assistance Publique-Hôpitaux de Paris, Hôpital Hôtel-Dieu, Centre d'Epidémiologie Clinique, Paris, France (L.T.); Neurology Department, Hospital Santo António, Centro Hospitalar do Porto, Largo Professor Abel Salazar, Porto, Portugal (R.F.); Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand (K.R.); Department of Neurology and Stroke Unit, University Hospital Basel, Switzerland (L.H.B.); Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, Queen Square, London, UK (L.H.B., M.M.B.); Department of Neurology, University Hospital Heidelberg, Im Neuenheimer Feld 400, Heidelberg, Germany (P.A.R.); and Stroke Prevention Research Unit, Nuffield Department of Clinical Neuroscience, University of Oxford, Oxford, UK (P.M.R.).
Abstract
BACKGROUND AND PURPOSE: Compared with carotid endarterectomy (CEA), carotid angioplasty and stenting (CAS) is associated with a higher risk of procedural stroke or death especially in patients with symptomatic stenosis. However, after the perioperative period, risk is similar with both treatments, suggesting that CAS could be an acceptable option in selected patients. METHODS: We performed systematic reviews of observational studies of procedural risks of CEA or CAS and extracted data on 9 predefined risk factors (age, contralateral carotid occlusion, coronary artery disease, diabetes mellitus, sex, hypertension, peripheral artery disease, and type and side of stenosis). We calculated pooled relative risks of procedural stroke or death. Factors with differential effects on risk of CAS versus CEA were identified by interaction tests and used to derive a rule. The rule was tested using individual patient data from randomized trials of CAS versus CEA from the Carotid Stenting Trialists' Collaboration (CSTC). RESULTS: We identified 170 studies. The effects of sex, contralateral occlusion, age, and restenosis (SCAR) on the procedural risk of stroke or death differed. Patients with contralateral occlusion or restenosis and women<75 years were at relatively low risk for CAS (SCAR negative), with all others being high risk (SCAR positive). Among the 3049 patients in the CSTC validation, 694 (23%) patients were SCAR negative. The pooled RR of procedural stroke and death with CAS versus CEA was 0.93 (0.49-1.77; P=0.83) in SCAR-negative and 2.41 (1.68-3.45; P<0.0001) in SCAR-positive patients (P [interaction]=0.05). CONCLUSIONS: The SCAR rule is potentially useful to identify patients in whom CAS has a similar risk of perioperative stroke or death to CEA.
BACKGROUND AND PURPOSE: Compared with carotid endarterectomy (CEA), carotid angioplasty and stenting (CAS) is associated with a higher risk of procedural stroke or death especially in patients with symptomatic stenosis. However, after the perioperative period, risk is similar with both treatments, suggesting that CAS could be an acceptable option in selected patients. METHODS: We performed systematic reviews of observational studies of procedural risks of CEA or CAS and extracted data on 9 predefined risk factors (age, contralateral carotid occlusion, coronary artery disease, diabetes mellitus, sex, hypertension, peripheral artery disease, and type and side of stenosis). We calculated pooled relative risks of procedural stroke or death. Factors with differential effects on risk of CAS versus CEA were identified by interaction tests and used to derive a rule. The rule was tested using individual patient data from randomized trials of CAS versus CEA from the Carotid Stenting Trialists' Collaboration (CSTC). RESULTS: We identified 170 studies. The effects of sex, contralateral occlusion, age, and restenosis (SCAR) on the procedural risk of stroke or death differed. Patients with contralateral occlusion or restenosis and women<75 years were at relatively low risk for CAS (SCAR negative), with all others being high risk (SCAR positive). Among the 3049 patients in the CSTC validation, 694 (23%) patients were SCAR negative. The pooled RR of procedural stroke and death with CAS versus CEA was 0.93 (0.49-1.77; P=0.83) in SCAR-negative and 2.41 (1.68-3.45; P<0.0001) in SCAR-positive patients (P [interaction]=0.05). CONCLUSIONS: The SCAR rule is potentially useful to identify patients in whom CAS has a similar risk of perioperative stroke or death to CEA.
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