Endarterectomy vs stenting for carotid artery stenosis: A systematic review and meta-analysis

Murad, M. Hassan; Flynn, David N.; Elamin, Mohamed B.; Guyatt, Gordon; Hobson, Robert W.; Erwin, Patricia J.; Montori, Víctor M.

doi:10.1016/j.jvs.2008.05.035

Cited by 65 publications

(53 citation statements)

References 30 publications

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“…These results suggest that endarterectomy has more favorable effects on periprocedural and long-term outcomes and should remain the treatment of choice for patients with carotid stenosis. Although our periprocedural results are similar to those of previous studies, [27][28][29] to our knowledge, our meta-analysis is the first to include the long-term results from Brooks et al, 22 EVA-3S, 15 and the International Carotid Stenting Study (ICSS). 26 With the inclusion of these recently available data, our meta-analysis has produced more precise estimates than those of previous studies in this area, including a previous Cochrane review by Bonati et al 30 (odds ratio for long-term stroke and periprocedural death, 1.39; 95% CI, 1.10-1.75).…”

Section: Discussionsupporting

confidence: 86%

Meta-Analysis of Randomized Controlled Trials Comparing the Long-Term Outcomes of Carotid Artery Stenting Versus Endarterectomy

Vincent

Eberg

Eisenberg

et al. 2015

Circ: Cardiovascular Quality and Outcomes

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Carotid artery stenting was developed as an alternative to endarterectomy for the management of patients with carotid stenosis in the 1990s. With the assumption that an endovascular approach would offer a more favorable safety profile than an open surgical procedure, the use of stenting increased significantly 1 after its entry into the market. In the United States, the use of stenting increased from 3% of patients undergoing carotid artery revascularization procedures in 1998 to 13% in 2008. 2 Despite this observed increase in utilization, the long-term safety and efficacy of stenting relative to endarterectomy remain unclear. Current guidelines recommend endarterectomy as first-line treatment for most patients with symptomatic carotid stenosis of 50% to 99%, and a perioperative risk of stroke or death that is <6%.3 With long-term results from randomized controlled trials (RCTs) now available, we addressed this issue via a meta-analysis of RCTs that compared the safety and efficacy of stenting with those of endarterectomy, with a particular focus on long-term outcomes. MethodsOur meta-analysis followed a prespecified protocol and is reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. 4 Search StrategyWe performed a systematic search of PubMed, EMBASE, MEDLINE, and the Cochrane Library Register of Controlled Trials online databases, from inception to October 22, 2014, for all RCTs that compared stenting with endarterectomy and reported periprocedural or long-term outcomes. We used Medical Subject Heading (MeSH) terms in PubMed and MEDLINE, EMTREE terms in EMBASE, and keyword search terms for carotid stenosis, stenting, carotid, and carotid endarterectomy in all 4 databases (Appendices I-IV in the Data Supplement). In PubMed, MEDLINE, and EMBASE, we then Background-Stenting is an endovascular alternative to endarterectomy for the management of carotid stenosis, but its long-term safety and efficacy relative to endarterectomy remain unclear. Our objective was to compare the safety and efficacy of stenting with those of endarterectomy, with a particular focus on long-term outcomes, via meta-analysis of randomized controlled trials (RCTs). Methods and Results-We systematically searched PubMed, EMBASE, MEDLINE, and the Cochrane Library for RCTs with ≥50 patients that compared stenting with endarterectomy in patients with carotid stenosis. Periprocedural and longterm outcomes were assessed, with data pooled across RCTs using random-effects models. Eight RCTs were included in our meta-analysis (n=7091), with follow-up ranging from 2.0 to 10.0 years. When compared with endarterectomy, stenting was associated with an increased risk of periprocedural stroke (relative risk, 1.49, 95% confidence interval [CI], 1.11 to 2.01; risk difference, 1.7%; 95% CI, 0.3 to 3.0) but a decreased risk of periprocedural myocardial infarction (relative risk, 0.47; 95% CI, 0.29 to 0.78; risk difference, −0.4%; 95% CI, −0.8% to 0.1%). During long-term follow-up, stenting was associa...

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Section: Discussionsupporting

confidence: 86%

Meta-Analysis of Randomized Controlled Trials Comparing the Long-Term Outcomes of Carotid Artery Stenting Versus Endarterectomy

Vincent

Eberg

Eisenberg

et al. 2015

Circ: Cardiovascular Quality and Outcomes

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“…458 Other meta-analyses found CAS to be inferior to CEA or associated with higher rates of periprocedural stroke. [613][614][615] In another meta-analysis of 11 trials that included 4796 patients (10 of which reported on short-term outcomes [nϭ4709] and 9 of which reported on intermediate-term outcomes, or 1 to 4 years), the risk of periprocedural mortality or stroke was lower with CEA than with CAS (OR 0.67, 95% CI 0.47 to 0.95; Pϭ0.025). This was based mainly on a lower risk of stroke (OR 0.65, 95% CI 0.43 to 1.00; Pϭ0.049), because the risk of death (OR 1.14, 95% CI 0.56 to 2.31; Pϭ0.727) and the composite endpoint of mortality or disabling stroke (OR 0.…”

Section: Meta-analyses Comparing Carotid Endarterectomy and Stentingmentioning

confidence: 99%

2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease

Brott¹,

Halperin²,

Abbara

et al. 2011

Stroke

140

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“…[29][30][31][32][33] Murad et al 29 used a random-effects meta-analysis to evaluate the death, stroke (disabling and non-disabling), and nonfatal MI rates at 30 days in 10 randomized controlled trials representing 3182 patients. They based equivalency of the 2 procedures on an absolute difference in events of ,2%.…”

Section: Discussionmentioning

confidence: 99%

Carotid Revascularization Using Endarterectomy or Stenting Systems (CaRESS):4-Year Outcomes

Zarins

White

Diethrich

et al. 2009

Journal of Endovascular Therapy

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¤ ¤Purpose: To examine the 4-year outcomes from Carotid Revascularization using Endarterectomy or Stenting Systems (CaRESS) in light of the current reimbursement guidelines for carotid artery stenting (CAS) from the Centers for Medicare and Medicaid Services (CMS).Methods: CaRESS was designed as a prospective, nonrandomized comparative cohort study of a broad-risk population of symptomatic and asymptomatic patients with carotid stenosis. In all, 397 patients (247 men; mean age 71 years, range 43-89) were enrolled and underwent carotid endarterectomy (CEA; n5254) or protected CAS (n5143). More than 90% of patients had .75% stenosis; two thirds were asymptomatic. The primary endpoints included (1) all-cause mortality, (2) any stroke, and (3) myocardial infarction (MI), as well as the composite endpoints of (4) death and any nonfatal stroke and (5) death, nonfatal stroke, and MI. The secondary endpoints were restenosis, repeat angiography, and carotid revascularization. All patients were classified with respect to surgical risk, symptom status, and stenosis grade based on criteria published by the CMS. In addition, separate analyses were performed comparing genders and octogenarians to those ,80 years old.Results: No significant differences in the primary outcome measures were found between the CEA and CAS groups in the 4-year analysis. The incidences of any stroke at 4 years were 9.6% for CEA and 8.6% for CAS (p50.444); when combined with death, the composite death/nonfatal stroke rates were 26.5% for CEA versus 21.8% for CAS (p50.361). The composite endpoint of death, nonfatal stroke, and MI at 4 years was 27.0% in CEA versus 21.7% in CAS (p50.273) patients. The secondary endpoints of restenosis (p50.014) and repeat angiography (p50.052) were higher in the CAS arm. There were no differences in any of the subgroups stratified according the CMS guidelines or in the gender comparison. Four-year incidences of death/nonfatal stroke and death/nonfatal stroke/MI were higher in the CEA arm among patients ,80 years of age (p50.049 and p50.030, respectively). There were no significant differences between these incidences in the octogenarian subgroup.

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Endarterectomy vs stenting for carotid artery stenosis: A systematic review and meta-analysis

Cited by 65 publications

References 30 publications

Meta-Analysis of Randomized Controlled Trials Comparing the Long-Term Outcomes of Carotid Artery Stenting Versus Endarterectomy

Meta-Analysis of Randomized Controlled Trials Comparing the Long-Term Outcomes of Carotid Artery Stenting Versus Endarterectomy

2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease

Carotid Revascularization Using Endarterectomy or Stenting Systems (CaRESS):4-Year Outcomes

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