Correlation of plaque vulnerability stratified by Carotid Plaque-Reporting and Data System with outcomes of endarterectomy vs stenting.

Abstract

Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are the main treatment options for carotid atherosclerotic stenosis; however, determining the most appropriate intervention remains challenging. This study evaluates whether the Carotid Plaque-Reporting and Data System (RADS) enhances risk stratification for ipsilateral recurrent stroke after CAS or CEA in patients with anterior circulation ischemic stroke and investigates whether stratification based on plaque characteristics can help to identify patient subgroups more likely to benefit from CEA vs CAS. This retrospective study included 636 patients who underwent carotid interventions, comprising 290 CEA and 346 CAS cases. Plaque characteristics were assessed using Plaque-RADS. Area under the curve (AUC) analysis with the DeLong test was used to compare predictive accuracy. Univariate and multivariate analyses were performed to identify factors associated with stroke recurrence, and event-free survival was compared between CEA and CAS in patients with different Plaque-RADS scores. The median follow-up duration for the overall cohort was 29 months (interquartile range, 12-51 months). Stroke recurrence occurred in 94 patients (14.8%) overall: 30 patients (10.3%) in the CEA group and 64 patients (18.5%) in the CAS group. The Carotid Plaque-RADS 4 classification outperformed all other imaging features, showing significantly higher C-index values and larger AUCs for primary outcome prediction (all P < .05). Multivariate Cox regression revealed that Plaque-RADS 4 (hazard ratio, 3.683; 95% confidence interval, 2.217-4.520; P < .001) and CAS treatment (hazard ratio, 1.630; 95% confidence interval, 1.055-2.520; P = .028) were independent predictors of stroke recurrence. For patients with Plaque-RADS 4, event-free survival was significantly higher with CEA compared with CAS (P = .004), whereas no significant difference was observed between CEA and CAS in patients with Plaque-RADS 3 (P = .639). Carotid Plaque-RADS demonstrated superior predictive accuracy for primary outcomes compared with individual plaque characteristics. CEA may provide better outcomes than CAS in patients with high-risk plaques (Plaque-RADS 4).