Effects of carotid endarterectomy or stenting on hemodynamic complications in the International Carotid Stenting Study:a randomized comparison

Background Carotid endarterectomy and carotid artery stenting are frequently complicated by hemodynamic instability. Aims The study aims to compare the incidence of hemodynamic complications between carotid artery stenting and carotid endarterectomy in the International Carotid Stenting Study (ISRCTN25337470). Methods Patients with symptomatic carotid stenosis were randomly allocated to carotid artery stenting or carotid endarterectomy. The occurrence of peri-procedural hemodynamic depression (severe bradycardia, asystole, or hypotension requiring treatment) and hypertension requiring treatment was assessed in a per-protocol analysis. We compared the rate of hemodynamic complications, determined independent predictors thereof, and assessed their relation with the composite outcome of all-cause death, stroke, and myocardial infarction within 30 days of treatment. Results A number of 766 carotid artery stenting and 819 carotid endarterectomy patients had a single completed intervention. Hemodynamic depression occurred in 13.8% after carotid artery stenting and in 7.2% after carotid endarterectomy (relative risk 1.9, 95% confidence interval 1.4-2.6, P < 0.0001). Hypertension requiring treatment occurred less often after carotid artery stenting than after carotid endarterectomy (relative risk 0.2, 95% confidence interval, 0.1-0.4, P < 0.0001). In carotid artery stenting patients, a history of cardiac failure was the strongest independent predictor of hemodynamic depression (relative risk 2.4, 95% confidence interval 1.3-4.8, P = 0.009). There was no statistically significant association between hemodynamic complications and the occurrence of the composite outcome. Conclusion Hemodynamic depression occurs more often after carotid artery stenting and severe hypertension more often after carotid endarterectomy, but these complications are not responsible for the excess of major perioperative events after carotid artery stenting.