Second asymptomatic carotid surgery trial (ACST-2): a randomised comparison of carotid artery stenting versus carotid endarterectomy

Introduction: Understanding the pathophysiological mechanism of procedural stroke during carotid intervention may help reduce the risk of stroke in those undergoing surgery. We therefore studied the features of procedural strokes within the first Asymptomatic Carotid Surgery Trial-1 (ACST-1) to identify the underlying pathophysiological mechanism. Methods: In ACST-1, 3,120 patients with severe asymptomatic carotid stenosis thought suitable for surgery were randomized to CEA or indefinite deferral of surgery. Information on procedural (within 30 days) stroke type, laterality, severity and timing was collected. Eight possible mechanisms were defined: embolism from the carotid artery, haemodynamic, thrombosis or occlusion of the carotid artery, hyperperfusion syndrome, cardioembolic, either carotid embolic or haemodynamic, either carotid embolic or thrombotic occlusion, or undetermined. Results: Procedural strokes occurred in 53 patients (2.7%). Strokes were predominantly ischaemic (n = 43; 81%), ipsilateral to the treated artery (n = 42; 79%), often occurred on the day of the operation (n = 32; 60%) and in over half the patients, were disabling or fatal (n = 27; 51%). The identified stroke mechanism was carotid embolic (n = 7), haemodynamic (n = 5), thrombosis or occlusion of the carotid artery (n = 9), hyperperfusion (n = 7), cardioembolic (n = 3), ‘probably carotid embolic or haemodynamic' (n = 7), ‘probably carotid embolic or thrombotic occlusion' (n = 3) and undetermined in 12 cases. Conclusion: In ACST-1, the risk of procedural stroke was low. Most strokes (60%) occurred on the day of the procedure and were caused by thrombosis or thrombotic occlusion of the ipsilateral carotid artery. These findings emphasize the importance of immediate assessment of the treated carotid artery when a stroke occurs after CEA.

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Angioplastica carotidea

Rivista di Neuroradiologia ◽

10.1177/197140099801100402 ◽

1998 ◽

Vol 11 (4) ◽

pp. 431-442 ◽

Cited By ~ 1

Author(s):

M. Puglioli ◽

R. Padolecchia ◽

P.L. Collavoli ◽

G. Parenti ◽

G. Orlandi ◽

...

Keyword(s):

Carotid Endarterectomy ◽

North American ◽

Carotid Atherosclerosis ◽

Sono State ◽

Carotid Surgery ◽

Asymptomatic Carotid ◽

Symptomatic Carotid ◽

Sono Stati ◽

Surgery Trial

L'endoarteriectomia, come confermano i risultati degli studi multicentrici NASCET (North American Symptomatic Carotid Endarterectomy Trial), ECST (European Carotid Surgery Trial) ed ACAS (Asymptomatic Carotid Atherosclerosis Study), rappresenta il trattamento di elezione delle stenosi aterosclerotiche interessanti il distretto extracranico dell'arteria carotide, sia nei pazienti sintomatici (stenosi > 70%) che asintomatici (stenosi > 60%). L'intervento chirurgico è gravato da un rischio cumulativo di morbilità-mortalità (stroke/morte) che il NASCET, l'ECST e l'ACAS segnalano, rispettivamente, nel 5,8%, 7,5% e 2,3%, insieme ad altre possibili complicanze: infarto miocardico (0,9%), paralisi di nervi cranici (7,6%), ematoma del collo (5,5%), infezioni (3,4%). Qualora, per ragioni cliniche od anatomiche, il rischio chirurgico sia troppo elevato, come nei pazienti cardiopatici, diabetici, con insufficienza polmonare o renale, con restenosi, con stenosi post-attiniche o fibrodisplastiche, con stenosi carotidee prossimali o distali, con lesioni «tandem», l'angioplastica transluminale percutanea (PTA) e/o lo Stenting carotideo possono rappresentare una valida alternativa terapeutica all'endoarteriectomia. In questo articolo presentiamo la nostra casistica relativa a 41 procedure (36 PTA; 5 Stenting), eseguite su 33 pazienti negli ultimi due anni. I trattamenti sono stati rivolti a 28 arterie carotidi interne, 4 arterie carotidi esterne, 2 arterie carotidi comuni, 2 tronchi anonimi; gli stents sono stati rilasciati in 4 arterie carotidi interne e in 1 arteria carotide comune. Le procedure regolarmente portate a termine sono state 37 (32 PTA; 5 Stents), con un ottimo risultato anatomico in 36 casi. Nei controlli a 6 mesi abbiamo riscontrato una ristenosi (< 60%), asintomatica. In questo articolo illustriamo il nostro protocollo, gli insuccessi tecnici, i risultati e le complicanze.

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Stent-Protected Angioplasty in Asymptomatic Carotid Artery Stenosis vs. Endarterectomy: SPACE2 – a Three-Arm Randomised-Controlled Clinical Trial

International Journal of Stroke ◽

10.1111/j.1747-4949.2009.00290.x ◽

2009 ◽

Vol 4 (4) ◽

pp. 294-299 ◽

Cited By ~ 66

Author(s):

T. Reiff ◽

R. Stingele ◽

H. H. Eckstein ◽

G. Fraedrich ◽

O. Jansen ◽

...

Keyword(s):

Primary Prevention ◽

Carotid Artery ◽

Carotid Endarterectomy ◽

Carotid Artery Stenting ◽

Carotid Artery Disease ◽

Controlled Clinical Trial ◽

Vascular Events ◽

Asymptomatic Carotid ◽

Symptomatic Carotid ◽

Asymptomatic Patients

Moderate to severe (≥70%) asymptomatic stenosis of the extracranial carotid artery leads to an increased rate of stroke of approximately 11% in 5 years. Patients with asymptomatic carotid stenosis, however, are also at a higher risk of nonstroke vascular events. The estimated annual risks of such events in patients with asymptomatic stenosis are 7% for a coronary ischaemic event and 4–7% for overall mortality. The superiority of carotid endarterectomy compared with medical treatment in symptomatic carotid disease is established, provided that the surgical procedure can be performed with a perioperative morbidity and mortality of <6%. The advantage of carotid endarterectomy for asymptomatic patients is less established. An alternative treatment, carotid artery stenting, has been developed. This treatment is used frequently in both symptomatic and asymptomatic patients. In the last decade, major advantages in medical primary prevention of cerebrovascular and cardiovascular disease have been accomplished. The control groups in the large trials for asymptomatic carotid artery disease (ACAS and ACST) originate from more than a decade ago and, for the most part, have not received a medical primary prevention strategy that would now be considered the standard according to current national and international guidelines. For this reason, a three-arm trial (SPACE2; http://www.space-2.de ) with a hierarchical design and a recruitment target of 3640 patients is chosen. Firstly, a superior trial of intervention (carotid artery stenting or carotid endarterectomy) vs. state-of-the-art conservative treatment is designed. In case of superiority of the interventions, a noninferiority end-point will be tested between carotid artery stenting and carotid endarterectomy. This trial is registered at Current Controlled Trials ISRCTN 78592017.

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Carotid Artery Stenting Versus Carotid Endarterectomy for Treatment of Asymptomatic Carotid Disease

Interventional Cardiology Clinics ◽

10.1016/j.iccl.2013.09.009 ◽

2014 ◽

Vol 3 (1) ◽

pp. 63-72

Author(s):

R. Kevin Rogers ◽

Sanjay Gandhi ◽

Kenneth Rosenfield

Keyword(s):

Carotid Artery ◽

Carotid Endarterectomy ◽

Carotid Artery Stenting ◽

Carotid Disease ◽

Asymptomatic Carotid

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Ten-year risk of stroke in patients with previous cerebral infarction and the impact of carotid surgery in the Asymptomatic Carotid Surgery Trial

International Journal of Stroke ◽

10.1177/1747493016660319 ◽

2016 ◽

Vol 11 (9) ◽

pp. 1020-1027 ◽

Cited By ~ 12

Author(s):

Jonathan Y Streifler ◽

Anne G den Hartog ◽

Samuel Pan ◽

Hongchao Pan ◽

Richard Bulbulia ◽

...

Keyword(s):

Cerebral Infarction ◽

Carotid Endarterectomy ◽

Carotid Stenosis ◽

Hazard Ratio ◽

Carotid Surgery ◽

Asymptomatic Carotid ◽

Risk Increase ◽

Surgery Trial ◽

The Impact

Background Silent brain infarcts are common in patients at increased risk of stroke and are associated with a poor prognosis. In patients with asymptomatic carotid stenosis, similar adverse associations were claimed, but the impact of previous infarction or symptoms on the beneficial effects of carotid endarterectomy is not clear. Our aim was to evaluate the impact of prior cerebral infarction in patients enrolled in the Asymptomatic Carotid Surgery Trial, a large trial with 10-year follow-up in which participants whose carotid stenosis had not caused symptoms for at least six months were randomly allocated either immediate or deferred carotid endarterectomy. Methods The first Asymptomatic Carotid Surgery Trial included 3120 patients. Of these, 2333 patients with baseline brain imaging were identified and divided into two groups irrespective of treatment assignment, 1331 with evidence of previous cerebral infarction, defined as a history of ischemic stroke or transient ischemic attack > 6 months prior to randomization or radiological evidence of an asymptomatic infarct (group 1) and 1002 with normal imaging and no prior stroke or transient ischemic attack (group 2). Stroke and vascular deaths were compared during follow-up, and the impact of carotid endarterectomy was observed in both groups. Results Baseline characteristics of patients with and without baseline brain imaging were broadly similar. Of those included in the present report, male gender and hypertension were more common in group 1, while mean ipsilateral stenosis was slightly greater in group 2. At 10 years follow-up, stroke was more common among participants with cerebral infarction before randomization (absolute risk increase 5.8% (1.8–9.8), p = 0.004), and the risk of stroke and vascular death was also higher in this group (absolute risk increase 6.9% (1.9–12.0), p = 0.007). On multivariate analysis, prior cerebral infarction was associated with a greater risk of stroke (hazard ratio = 1.51, 95% confidence interval: 1.17–1.95, p = 0.002) and of stroke or other vascular death (hazard ratio = 1.30, 95% confidence interval: 1.11–1.52, p = 0.001). At 10 years, greater absolute benefits from immediate carotid endarterectomy were seen in those patients with prior cerebral infarction (6.7% strokes immediate carotid endarterectomy vs. 14.7% delayed carotid endarterectomy; hazard ratio 0.47 (0.34–0.65), p = 0.003), compared to those lower risk patients without prior cerebral infarction (6.0% vs. 9.9%, respectively; hazard ratio 0.61 (0.39–0.94), p = 0.005), though it must be emphasized that the first Asymptomatic Carotid Surgery Trial was not designed to test this retrospective and non-randomized comparison. Conclusions Asymptomatic carotid stenosis patients with prior cerebral infarction have a higher stroke risk during long-term follow-up than those without prior cerebral infarction. Evidence of prior ischemic events might help identify patients in whom carotid intervention is particularly beneficial.

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