Carotid Artery Stenting Versus Endarterectomy for Stroke Prevention: A Meta-Analysis of Clinical Trials

Partha Sardar; Saurav Chatterjee; Herbert D Aronow; Amartya Kundu; Preethi Ramchand; Debabrata Mukherjee; Ramez Nairooz; William A Gray; Christopher J White; Michael R Jaff; Kenneth Rosenfield; Jay Giri

doi:10.1016/j.jacc.2017.02.053

Carotid Artery Stenting Versus Endarterectomy for Stroke Prevention: A Meta-Analysis of Clinical Trials

J Am Coll Cardiol. 2017 May 9;69(18):2266-2275. doi: 10.1016/j.jacc.2017.02.053.

Authors

Affiliations

¹ Division of Cardiovascular Medicine, University of Utah, Salt Lake City, Utah.
² St. Luke's-Roosevelt Hospital of the Mount Sinai Health System, New York, New York.
³ Cardiovascular Institute, Warren Alpert Medical School at Brown University, Providence, Rhode Island.
⁴ Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts.
⁵ Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania.
⁶ Texas Tech University Health Sciences Center, El Paso, Texas.
⁷ University of Arkansas for Medical Sciences, Little Rock, Arkansas.
⁸ Main Line Health System, Philadelphia, Pennsylvania.
⁹ John Ochsner Heart and Vascular Institute, Ochsner Clinical School of the University of Queensland, Ochsner Medical Center, New Orleans, Louisiana.
¹⁰ Paul and Phyllis Fireman Vascular Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
¹¹ Penn Cardiovascular Outcomes, Quality and Evaluative Research Center, University of Pennsylvania, Philadelphia, Pennsylvania; Cardiovascular Medicine Division, University of Pennsylvania, Philadelphia, Pennsylvania. Electronic address: giri.jay@gmail.com.

PMID: 28473130
DOI: 10.1016/j.jacc.2017.02.053

Abstract

Background: Data conflict regarding the relative effectiveness of carotid artery stenting (CAS) and carotid artery endarterectomy (CEA) for the prevention of stroke due to carotid artery stenosis.

Objectives: The authors performed an updated meta-analysis evaluating the efficacy and safety of CAS versus CEA, given recently published clinical trial data.

Methods: Databases were searched through April 30, 2016. Randomized trials with ≥50 patients, that had exclusive use of embolic-protection devices, and that compared CAS against CEA for the treatment of carotid artery stenosis were selected. We calculated summary odds ratios (ORs) and 95% confidence intervals (CIs) using a random-effects model.

Results: We analyzed 6,526 patients from 5 trials with a mean follow-up of 5.3 years. The composite outcome of periprocedural death, stroke, myocardial infarction (MI), or nonperiprocedural ipsilateral stroke was not significantly different between therapies (OR: 1.22; 95% CI: 0.94 to 1.59). The risk of any periprocedural stroke plus nonperiprocedural ipsilateral stroke was higher with CAS (OR: 1.50; 95% CI: 1.22 to 1.84). The risk of higher stroke with CAS was mostly attributed to periprocedural minor stroke (OR: 2.43; 95% CI: 1.71 to 3.46). CAS was associated with significantly lower risk of periprocedural MI (OR: 0.45; 95% CI: 0.27 to 0.75); cranial nerve palsy (OR: 0.07; 95% CI: 0.04 to 0.14); and the composite outcome of death, stroke, MI, or cranial nerve palsy during the periprocedural period (OR: 0.75; 95% CI: 0.60 to 0.93).

Conclusions: CAS and CEA were associated with similar rates of a composite of periprocedural death, stroke, MI, or nonperiprocedural ipsilateral stroke. The risk of long-term overall stroke was significantly higher with CAS, and was mostly attributed to periprocedural minor stroke. CAS was associated with lower rates of periprocedural MI and cranial nerve palsy than CEA.

Keywords: carotid artery endarterectomy; carotid artery stenting; stroke.

Publication types

Comparative Study
Meta-Analysis

MeSH terms

Carotid Stenosis / surgery*
Clinical Trials as Topic
Endarterectomy, Carotid / mortality*
Humans
Stents / adverse effects
Stents / statistics & numerical data*
Stroke / prevention & control*
Treatment Outcome