Long-Term Outcomes of Carotid Artery Stenting vs. Endarterectomy

Study Questions:

What is 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:

The investigators 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 long-term outcomes were assessed, with data pooled across RCTs using random-effects models.

Results:

Eight RCTs were included in the meta-analysis (n = 7,091), 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], 1.11-2.01; risk difference, 1.7%; 95% CI, 0.3-3.0), but a decreased risk of periprocedural myocardial infarction (MI) (relative risk, 0.47; 95% CI, 0.29-0.78; risk difference, −0.4%; 95% CI, −0.8% to 0.1%). During long-term follow-up, stenting was associated with an increased risk of stroke (relative risk, 1.36; 95% CI, 1.16-1.61) and a composite endpoint of ipsilateral stroke, periprocedural stroke, or periprocedural death (relative risk, 1.45; 95% CI, 1.20-1.75).

Conclusions:

The authors concluded that although stenting has more favorable periprocedural outcomes with respect to MI, the observed increased risk of stroke and death throughout follow-up with stenting suggests that endarterectomy remains the treatment of choice for carotid stenosis.

Perspective:

This study reports that stenting was associated with a decreased risk of periprocedural MI, hematoma, and cranial nerve palsy, but with an increased risk of most periprocedural stroke outcomes. Furthermore, the increased risk of stroke and an increased risk of a composite endpoint of ipsilateral stroke, periprocedural stroke, or periprocedural death persisted throughout follow-up. Overall, these data appear to suggest that endarterectomy remains the treatment of choice for the management of carotid stenosis with the understanding that significant heterogeneity was present among RCTs in this analysis with respect to duration of follow-up, patient recruitment periods, types of stents used, minimal operator requirements for participation, use of embolic protection devices, and patient characteristics.

Clinical Topics: Invasive Cardiovascular Angiography and Intervention, Vascular Medicine, Interventions and Vascular Medicine

Keywords: Carotid Stenosis, Cranial Nerve Diseases, Endarterectomy, Endarterectomy, Carotid, Hematoma, Myocardial Infarction, Risk, Stents, Stroke


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