Carotid endarterectomy and stenting in France: A 10-year nationwide evaluation of practice and outcomes

Abstract

Background:

Carotid stenosis accounts for 20–30% of ischemic strokes. In France, management practices for symptomatic and asymptomatic disease remain heterogeneous. This study assessed the nationwide trends and outcomes of carotid endarterectomy (CEA) and carotid artery stenting (CAS) from 2011 to 2020.

Methods:

Using the French National Health Data System, we identified patients who underwent CEA or CAS for carotid stenosis. Symptomatic status was defined by stroke or transient ischemic attack within 6 months before intervention. Comorbidities were measured using the Charlson Comorbidity Index. The primary outcome was 30-day stroke or all-cause death.

Results:

Among 149,273 patients (85% asymptomatic), 4.8% of asymptomatic and 3.5% of symptomatic patients underwent CAS; the remaining patients underwent CEA. CAS recipients had greater comorbidity (Charlson ⩾ 3: 53% vs 39% in asymptomatic patients; 75% vs 66% in symptomatic patients). Thirty-day stroke/death occurred in 1.8% of asymptomatic patients (CAS 3.2% vs CEA 1.7%, p < 0.001) and 12.6% of symptomatic patients (CAS 15.5% vs CEA 12.6%). After multivariable adjustment, CAS was independently associated with higher risks of 30-day stroke and stroke/death compared with CEA. Five-year mortality was higher after CAS (28.5%) versus 20.9% after CEA. Cranial nerve injury was more frequent after CEA in symptomatic patients. Preoperative statin and antiplatelet use was lower in symptomatic patients (67.9% and 67.1%, respectively) versus asymptomatic patients (84.5% and 92.2%, respectively).

Conclusions:

CEA remains the predominant treatment for carotid stenosis in France, whereas CAS is mainly used in higher-risk patients. Early postoperative complications are more frequent in symptomatic cases, and lower preoperative medical therapy use highlights suboptimal secondary prevention in this group.