Carotid Endarterectomy Versus Stenting: A Meta-Analysis of Randomized Trials

Abstract

230Ischemic stroke is the leading cause of permanent disability in the developed world.1 Up to 20% of ischemic strokes result from atherosclerotic stenosis of the internal carotid artery. 2 Carotid endarterectomy (CEA) has been shown to be of benefit in the treatment of symptomatic and asymptomatic carotid artery stenosis by several large randomized controlled trials (RCTs). [3][4][5][6][7] Over the past decade, however, a growing interest has arisen in carotid artery stenting (CAS) as a less invasive means of carotid revascularization.Disparate results have been reported by RCTs investigating the relative efficacy of CAS and CEA. [8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23] Three trials were stopped prematurely after their interim analyses revealed an increased risk of stroke following CAS. 13,14,16,23 In contrast, six ABSTRACT: Background: A meta-analysis of randomized controlled trials (RCTs) was conducted to update the available evidence on the safety and efficacy of carotid endarterectomy (CEA) versus carotid artery stenting (CAS) in the treatment of carotid artery stenosis. Methods: A comprehensive search was performed of MEDLINE, EMBASE, CENTRAL, bibliographies of included articles and past systematic reviews, and abstract lists of recent scientific conferences. For each reported outcome, a Mantel-Haenszel random-effects model was used to calculate odds ratios (ORs) and 95% confidence intervals (CI). The I 2 statistic was used as a measure of heterogeneity. Results: Twelve RCTs enrolling 6,973 patients were included in the meta-analysis. Carotid artery stenting was associated with a significantly greater odds of periprocedural stroke (OR 1.72, 95% CI 1.20 to 2.47) and a significantly lower odds of periprocedural myocardial infarction (OR 0.47, 95% CI 0.29 to 0.78) and cranial neuropathy (OR 0.08, 95% CI, 0.04 to 0.16). The odds of periprocedural death (OR 1.11, 95% CI 0.56 to 2.18), target vessel restenosis (OR 1.95, 95% CI 0.63 to 6.06), and access-related hematoma were similar following either intervention (OR 0.60, 95% CI 0.30 to 1.21). Conclusions: In comparison with CEA, CAS is associated with a greater odds of stroke and a lower odds of myocardial infarction. While the results our meta-analysis support the continued use of CEA as the standard of care in the treatment of carotid artery stenosis, CAS is a viable alternative in patients at elevated risk of cardiac complications. Bien que les résultats de notre méta-analyse soient en faveur de continuer à utiliser l'EC comme norme de soins dans le traitement de la sténose carotidienne, la PEV est une alternative valable chez les patients à risque élevé de complications cardiaques.

Malignant Emboli on Transcranial Doppler During Carotid Stenting Predict Postprocedure Diffusion-Weighted Imaging Lesions

“…1 This is associated with a high incidence (up to 50%) 2 of new ischemic lesions on MRI of the brain performed after the procedure. Although it is imperative to improve the safety of the procedure, investigating the relative safety of each step will be critical to guide future procedure modifications.…”

Laboratory-Based Markers as Predictors of Brain Infarction During Carotid Stenting: a Prospective Study

“…In the last decade, carotid artery stenting (CAS) has become an alternative treatment for carotid stenosis because general anesthesia and surgical incisions can be avoided. These features have reduced the incidence of postoperative wound problems and injury to the cranial nerve compared with surgery 7,8) . Recent studies have shown carotid endarterectomy and CAS to be associated with a similar prevalence of postoperative death and disabling stroke, but silent infarctions in the brain can be detected more often after CAS [9][10][11] .…”

When Is Carotid Angioplasty and Stenting the Cost-Effective Alternative for Revascularization of Symptomatic Carotid Stenosis? A Canadian Health System Perspective

“…The estimates of the clinical outcomes in the periprocedural (30-day) period were pooled from the results of a recent meta-analysis, 4 which included 12 major carotid revascularization trials enrolling 6973 patients (Table 1). This meta-analysis did not separately report the rates of periprocedural major and minor strokes.…”

“…Data from this recent meta-analysis were reanalyzed to provide estimates of periprocedural major and minor strokes. 4 The long-term clinical outcomes in those who survived the periprocedural period reported in included studies by Yavin et al 4 were pooled to estimate the annual incidence of major stroke, minor stroke, and death, excluding the first 30 days. The annual risk of each outcome was calculated by dividing the total number of patients with the outcome by the number of follow-up years (excluding outcomes occurring in the first 30 days).…”

“…3 Stroke is an uncommon but feared complication of carotid revascularization. 4 Stroke is more common after CAS, and though most of these periprocedural strokes are clinically minor, they contribute to the cumulative disability associated with the procedure. 5 The largest randomized trial comparing CAS versus CEA (the Carotid Revascularization Endarterectomy versus Stenting Trial [CREST]) concluded that the outcomes after CEA versus CAS were similar because a higher risk of myocardial infarction (MI) after CEA was balanced by a higher risk of stroke after CAS.…”