Systematic Review and Meta-Analysis of Carotid Artery Stenting Versus Endarterectomy for Carotid Stenosis

Abstract

There are disparities among the results of meta-analyses under different circumstances of carotid artery stenting (CAS) versus endarterectomy (CEA) for carotid stenosis. This study aimed to assess the efficacies of CAS and CEA for carotid stenosis at 5-year intervals and worldwide.Comparative studies simultaneously reporting CAS and CEA for carotid stenosis with at least 10 patients in each group were identified by searching PubMed and Embase in accordance with preferred reporting items for systematic reviews and meta-analyses guidelines, and by reviewing the reference lists of retrieved articles.The studies were stratified into different subgroups according to the publication year, location in which the study was mainly performed, and randomized and nonrandomized study designs.Thirty-five comparative studies encompassing 27,525 patients were identified. The risk ratios (RRs) of stroke/death when CAS was compared with CEA within 30 d of treatment were 1.51 (95% CI 1.32–1.74, P < 0.001) for overall, 1.50 (95% CI 1.14–1.98, P = 0.004) from 2011 to 2015, 1.61 (95% CI 1.35–1.91, P < 0.001) from 2006 to 2010, 1.59 (95% CI 1.27–1.99, P < 0.001) in North America, 1.50 (95% CI 1.24–1.81, P < 0.001) in Europe, 1.63 (95% CI 1.31–2.02, P < 0.001) for randomized, and 1.44 (95% CI 1.20–1.73, P < 0.001) for nonrandomized comparative studies. CEA decreased the risks of transient ischemic attack at 30 d (RR: 2.07, 95% CI 1.50–2.85, P < 0.001) and restenosis at 1-year (RR: 1.97, 95% CI 1.28–3.05, P = 0.002). Data from follow-up showed that the RRs of stroke/death were 0.74 (95% CI 0.55–0.99, P = 0.04) at 1 year, 1.24 (95% CI 1.04–1.46, P = 0.01) at 4 year, and 2.27 (95% CI 1.39–3.71, P = 0.001) at 10 year. This systematic review, compared with those of other meta-analyses, included all available comparative studies and analyzed them at 5-year intervals, in different continents, and under different study designs. Current evidence suggests that the efficacy of CEA is superior to CAS for freedom from stroke/death within 30 d, especially from 2006 to 2015, in North America and Europe. Meanwhile, the superiority was also observed for restenosis at 1-year, transient ischemic attack within 30 d, and stroke/death at 4- and 10-year follow-ups.

Carotid Stenting Versus Endarterectomy for Asymptomatic Carotid Artery Stenosis

“…The results of previous systematic reviews and meta-analyses of all patients (asymptomatic+symptomatic) are also consistent with our results. Zhang et al 44 found that patients randomized to CAS had higher risks of periprocedural stroke or death, restenosis at 1-year follow-up, periprocedural transient ischemic attack, and stroke or death at both 4-and 10-year follow-ups. Brahmanandam et al 45 and Liu et al 46 also found CEA to be superior to CAS for periprocedural stroke or death.…”

Recent Update on Carotid Endarterectomy versus Carotid Artery Stenting

“…Recent meta-analyses [26][27][28][29][30][31][32] , which included the latest large studies, seem to support the superiority of CEA over CAS in the periprocedural period whereas longterm results are inconclusive ( table 2 ). The meta-analysis [29] published in 2011 showed that CAS, when compared with CEA, was associated with an increased risk of periprocedural outcomes of death, MI or stroke except for cranial nerve injury and MI.…”

“…A meta-analysis of Vincent et al [30] revealed that the higher cumulative incidence of stroke-related events throughout long-term follow-up was possibly caused by an increased risk during the periprocedural period. Interestingly, Zhang et al [32] systematically reviewed the data comparing CAS with CEA in the treatment of CS and pooled the data to analyze the results in different aspects. This study concluded that CEA is superior to CAS with regard to the stroke or death rate within 30 days, especially from 2006 to 2015, in North America and Europe.…”

The patient with neurological and psychological disorders

“…1 Carotid stenting has been trialled but current evidence supports carotid endarterectomy as the treatment of choice in these cases. 2 Timing of non-stroke-related surgery depends on the condition of the patient and the urgency of surgery; elective surgery should be deferred for at least 3 months. This time can be utilized to address co-morbid conditions pharmacologically or by lifestyle modification (e.g.…”