Long-term efficacy and safety of carotid artery stenting versus endarterectomy: A meta-analysis of randomized controlled trials

Abstract

BackgroundMany recent trials have investigated the long-term efficacy and safety of endarterectomy versus stenting in treating patients with carotid artery stenosis. We aimed to determine the long-term comparative efficacy and safety of both procedures by pooling this evidence in a meta-analysis.MethodsWe searched PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials for studies published until May 6, 2016. Randomized controlled trials, which reported outcomes of interest with a median follow-up of at least 4-year, were included.ResultsEight trials involving 7005 patients and 41824 patient-years of follow-up were included. In terms of the periprocedural outcomes, stenting was associated with a lower risk of myocardial infarction (OR: 0.51; 95% CI: 0.33 to 0.80; P = 0.003) but a higher risk of death or stroke (the composite endpoint, OR: 1.76; 95% CI: 1.38 to 2.25; P < 0.0001), a result that was primarily driven by minor stroke (OR: 2.19; 95% CI: 1.59 to 3.01; P < 0.0001), less so by periprocedural death (OR: 1.68; 95% CI: 0.82 to 3.44; P = 0.16) and major stroke (OR: 1.41; 95% CI: 0.95 to 2.09; P = 0.09). In terms of the long-term outcomes, stenting was associated with a higher risk of stroke (OR 1.45; 95% CI: 1.22 to 1.73; P < 0.0001) and the composite outcome of death or stroke (OR 1.25; 95% CI: 1.05 to 1.48; P = 0.01). No difference was found in long-term all-cause mortality between stenting and endarterectomy (OR: 1.09; 95% CI: 0.95 to 1.26; P = 0.21) and restenosis (OR: 1.48 (95% CI: 0.93 to 2.35; P = 0.10). No evidence of significant heterogeneity was found in any of the analyses.ConclusionsCarotid endarterectomy was found to be superior to stenting for short- and long-term outcomes, although endarterectomy was associated with a higher risk of periprocedural myocardial infarction. Carotid endarterectomy should be offered as the first choice for carotid stenosis at present, however, more evidence is needed because rapid progress in concurrent devices and medical treatments is being made.

Comparison of Long Term Prognosis between Carotid Endarterectomy versus Stenting; A Korean Population-Based Study Using National Insurance Data

“…The prognosis of patients who received carotid revascularization in this study differed between CAS and CEA groups. These results are similar to those of previous studies and meta-analysis [6,12]. Because of the lack of evidence, current guidelines recommend CAS as an alternative to CEA in limited patients [3,13].…”

“…However, there was difference in the all-cause mortality between the groups in this study like a prior multi-center cohort study [7]. The long-term risk of ischemic stroke after carotid revascularization was higher in the CAS group than CEA group in this study, and the HR was similar to the result of a meta-analysis and nationwide cohort study [6]. The incidence of ischemic stroke after carotid revascularization in this study was higher than those of previous studies, but the long-term mortality was similar.…”

“…Long-term all-cause mortality was not different significantly between CAS and CEA in the meta-analysis of a randomized controlled study and nationwide cohort study [6,17]. However, there was difference in the all-cause mortality between the groups in this study like a prior multi-center cohort study [7].…”

“…As a result, there has been a report that CAS is performed three times more frequently than CEA every year in Korea [5]. In most studies evaluating patient outcomes for those receiving carotid revascularization, there were more patients who received CEA than CAS, except for randomized clinical trials [6]. There was no difference in long-term mortality in the randomized clinical trials, but the prognosis of patients with CEA was better in the observational study [7].…”

Presence of Contralateral Carotid Occlusion Is Associated With Increased Periprocedural Stroke Risk Following CEA but Not CAS: A Meta-analysis and Meta-regression Analysis of 43 Studies and 96,658 Patients

“…Selection of patients for carotid revascularization and selection of the most appropriate revascularization modality depends on comorbidities, symptoms, and anatomy. [64][65][66][67][68] The superiority of CEA vs CAS in the treatment of symptomatic stenosis is well established, while the majority of studies supported noninferiority of CAS vs CEA for treatment of asymptomatic stenosis. 65,69 CEA is also preferred in patients >70 years old, as CAS is associated with increased 30-day stroke rates in this age group.…”