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

Leo Bonati, Jorg Ederle, Joanna Dobson, Stefan Engelter, Roland Featherstone, Peter Gaines, Jonathan Beard, Graham Venables, Hugh Markus, Andrew Clifton, Peter Sandercock, Martin Brown, J Bland, Melita Brown, T Buckenham, A Clifton, Renay Taylor, Gloria Tognoni, Charles Warlow, T BleakleyDavid Colquhoun, Lucy Coward, F Crawley, P Dobinson, S Holder, Dominick McCabe, Anthony Pereira, James Rogers, Louise Silver, Julie Burrett, John Crowther, M Dobson, B Hafner, John Heineman, Caroline Hope, Susan Knight, A Naughten, A Radley, Sarah Richards, Douglas Smith, S Wenzel, Michelle Harrison, Jose Ferro, Jane Beard, C Bladin, G Donnan, Gary Fell, Gregory Fitt, John Royle, Stephen Davis, Richard Gerraty, Peter Mitchell, Marcel Goodman, Graeme Hankey, Makhan Khangure, Michael Lawrence-Brown, Jennie Linto, William McAuliffe, F Prendergast, K Siennarine, Edward Stewart-Wynne, S Grahovac, William Morrish, N Pageau, C Pringle, D Richard, J Malms, Lutz Reiher, Mario Siebler, Giorgio Belloni, Mauro Porta, Angel Chamorro, Nicolas Vila, Vicente Riambau, Francisco Vazquez, Fernando Boza, J Garcia Rodriguez, Alberto Gil-Peralta, Alejandro Gonzalez, Jose Gonzalez-Marcos, Antonio Mayol Deya, J Rauno, Eberhard Kirsch, Phillippe Lyrer, J Rem, J Bogousslavsky, Antoine Uske, James Beard, Trevor Cleveland, Colin Doyle, Arul Sivaguru, P Leopold, Thomas Loosemore, Daniel McCabe, Andreia Pereira, Jane Rogers, Ronald Taylor, Thyge Enevoldson, G Gilling-Smith, Peter Harris, Thomas Nixon, Paul Baskerville, Thomas Cox, Simon Fraser, Melanie Jeffrey, Jane Molloy, Paul Butler, John Dick, F Frankel, Andrew Bradbury, Donald Collie, John Murie, Charles Ruckley, David Schultz, Robin Sellar, Joanna Wardlaw, Raymond Ashleigh, Charles McCollum, Paul O'Neill, Anil Gholkar, Alexander Mendelow, Timothy Walls, Heather Angus-Leppan, Shawn Halpin, Jocelyn Hughes, Ian Lane, Mark Wiles, Andrew Wood, Philip Birch, Jonathan Earnshaw, Geraint Fuller, Brian Heather, Keith Poskitt, A Tottle, Darren Hope, David Jefferson, Norman McConachie, Martin Duddy, M Heafield, R Vohra, R Collins

    Research output: Contribution to journalArticlepeer-review

    29 Citations (Scopus)

    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
    Number of pages9
    JournalInternational Journal of Stroke
    Volume9
    Issue number3
    DOIs
    Publication statusPublished - 1 Apr 2014

    Keywords

    • Atherosclerosis
    • Carotid stenosis
    • Endarterectomy
    • Endovascular treatment
    • Plaque length
    • Restenosis

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