Background and Aims

ACST-2 is an international randomised trial comparing carotid endarterctomy (CEA) with carotid stenting (CAS), randomising patients for whom a carotid procedure is considered definitely necessary, both procedures seem anatomically feasible, and there is substantial uncertainty as to which of the two would be better for such individuals.

Primary objectives: compare 1) peri-procedural risks (myocardial infarction [MI], stroke and death within the first month after the allocated CEA or CAS), and 2) long-term (up to 5 or more years) prevention of stroke, particularly disabling or fatal stroke, in subsequent years.

Methods

Logrank analyses will compare stroke rates between those allocated CEA and those allocated CAS in specific time periods, with the main trial analyses on an ‘intention-to-treat’ basis. By the end of the recruitment period, there will be about 5 years follow-up, with analyses of the early effects of CEA vs CAS on the annual incidence of various types of stroke, disabling stroke and fatal stroke. Continued follow-up will allow more powerful analyses of these longer-term outcomes.

Results

By December 2020, 3638 patients from`133 centres in 33 countries were randomised; 2554 (70.2% men) and 1084 women with a median ipsilateral carotid stenosis of 80% (range 60-99%). 1290 patients (35.5%) had coronary artery disease, 224 (6.1%) had atrial fibrillation, 1088(29.9%) were diabetic and 91%, 8.4% 88.3% and 85.6% were taking antiplatelet, anticoagulant, BP-lowering and lipid-lowering treatments. Follow-up was 4.85(IQR2.41-7.76) years.

Results will be presented at WSC.

Conclusions

ACST-2 is the largest trial comparing CEA and CAS; these results will provide future guidance to clinicians worldwide.