In patients with symptomatic carotid stenoses, stent-protected angioplasty and carotid endarterectomy are associated with similar rates of ipsilateral stroke at two and four years' follow-up.

In patients with symptomatic carotid stenoses, stent-protected angioplasty and carotid endarterectomy are associated with similar rates of ipsilateral stroke at two and four years' follow-up, according to the results of two studies appearing in the September 6th online issue of The Lancet Neurology.

Still, the findings from the second study suggest that the periprocedural risks of stent-protected angioplasty must be reduced before it can be considered a viable alternative to surgery.

In the Stent-Protected Angioplasty versus Carotid Endarterectomy (SPACE) study, Dr. Peter Ringleb, from the University of Heidelberg in Germany, and colleagues assessed the 2-year clinical outcomes of 1214 patients with severe stenosis (at least 70 per cent) who were randomized to receive one of these interventions.

The rate of ipsilateral stroke up to two years and any periprocedural stroke or death in the angioplasty group was not significantly different from that in the surgery group -- about 9 per cent for both.

By contrast, recurrent carotid stenosis at two years was more common with angioplasty. On intention-to-treat analysis, the rate with angioplasty was 10.7 per cent, while the rate with surgery was 4.6 per cent (p = 0.0009).

In the Endarterectomy Versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis (EVA-3S) trial, Dr. Jean-Louis Mas, from Hopital Sainte-Anne in Paris, and co-researchers examined the impact of these interventions in 527 patients with symptomatic stenosis of at least 60 per cent.

At four years, the cumulative risk of periprocedural stroke or death and non-procedural ipsilateral stroke was 11.1 per cent with angioplasty, but only 6.2 per cent with endarterectomy (p = 0.03).

This difference, however, was mostly due to a higher risk of periprocedural stroke or death with angioplasty, the authors explain. When periprocedural risks were removed from the analysis, angioplasty and endarterectomy had similar low rates of ipsilateral stroke.

"The results from several randomized trials now suggest that carotid angioplasty with stenting is as durable as carotid endarterectomy," Dr. A. Ross Naylor, from Leicester Royal Infirmary in the UK, commented in an editorial. A meta-analysis of patient-level data is now needed to determine the optimal candidates for angioplasty versus surgery, he added.

Lancet Neurol 2008.