Stenting Riskier for Older Patients With Blocked Carotid Artery

FRIDAY Sept. 10, 2010 -- For patients aged 70 and older who have a blocked neck artery, inserting a stent to reopen the artery is riskier than surgically widening the artery, a new study finds.

But for younger patients, stenting may be a viable option, the researchers say.

The carotid arteries, located on each side of the neck, are the major supplier of blood to the brain. When they become blocked or narrowed -- a condition known as carotid stenosis -- strokes can result.

Earlier research found that treating carotid stenosis with stenting raised the risk of stroke more than surgery to widen the artery (endarterectomy). But in this new study, British researchers determined that the risk of stenting is age-related.

"For patients with recent relevant symptoms who need treatment for carotid stenosis, surgery should be the first choice in older patients," said researcher Dr. Martin M. Brown, professor of stroke medicine at the National Hospital for Neurology and Neurosurgery and Institute of Neurology at the University College London in the United Kingdom.

In patients 70 and older, "stenting was on average about twice as likely to cause a stroke or kill the patient as carotid endarterectomy," Brown said.

"In contrast, in patients younger than 70, the risk of stroke or death associated with stenting was half that of older patients and was very similar to the risk of surgical carotid endarterectomy," Brown added. "In younger patients, stenting might be a suitable alternative to carotid surgery," he concluded.

"Interestingly, the risk of stroke or death with surgical carotid endarterectomy did not alter substantially with age," Brown noted.

For the study, published in the Sept. 10 online edition of The Lancet, Brown and colleagues studied three trials that included 3,433 patients who had symptoms of carotid stenosis. In each trial, the researchers looked for causes of stroke or death.

Those who received stents had a 53 percent higher risk of having a stroke or dying in the four months after the procedure compared with patients who underwent a carotid endarterectomy, the researchers found.

But among those younger than 70, the risk for stroke or death was similar in both procedures. For patients 70 and older, the risk for stroke or death was two times higher in the stent group than for those who underwent endarterectomy (12 percent versus 5.9 percent).

Moreover, in the 30 days following treatment, the risk for stroke or death among the under-70 patients was similar, while 10.5 percent of the 70-and-older group who received stents had a stroke or died, compared with 4.4 percent of the carotid endarterectomy patients, the researchers found.

Dr. Larry B. Goldstein, professor of neurology and director of the Duke Stroke Center at Duke University Medical Center, said another new trial -- CREST -- supports the study results. CREST is the largest trial to date comparing endarterectomy with stenting in patients with a narrowing of the carotid artery, Goldstein said.

"CREST found no difference in the trial's primary outcomes of stroke, death or myocardial infarction [heart attack], but a higher risk of stroke in those having stenting that was balanced by a higher risk of heart attack in those having endarterectomy," he said. The new British study only looked at the rate of stroke and death; findings for heart attack were not part of the methodology.

"Similar to this study, CREST found increased risk of stenting versus endarterectomy in older [patients] as compared to younger patients in whom outcomes seemed better with stenting," Goldstein said.

Many experts had thought that stenting, which is less invasive than endarterectomy, would be safer for older patients, but taken together, this study and CREST suggest that may not be true, he said.

More information

For more information on carotid artery stenosis, visit the American Heart Association.

Posted: September 2010


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