CAS vs. CEA for Asymptomatic Carotid Artery Stenosis

Study Questions:

What is the comparative efficacy and safety of carotid stenting (CAS) versus carotid endarterectomy (CEA) in asymptomatic carotid stenosis patients?

Methods:

The investigators systematically searched EMBASE, PubMed, MEDLINE, and the Cochrane Library for randomized controlled trials comparing CAS to CEA in asymptomatic patients using a prespecified protocol. Two independent reviewers identified randomized controlled trials meeting the inclusion/exclusion criteria, extracted relevant data, and assessed quality using the Cochrane risk of bias tool. Random-effects models with inverse-variance weighting were used to estimate pooled risk ratios (RRs) comparing the incidences of periprocedural and long-term outcomes between CAS and CEA.

Results:

Eleven reports of five randomized controlled trials were identified for inclusion (n = 3,019) of asymptomatic patients. The pooled incidences of any periprocedural stroke (RR, 1.84; 95% confidence interval [CI], 0.99–3.40), periprocedural nondisabling stroke (RR, 1.95; 95% CI, 0.98–3.89), and any periprocedural stroke or death (RR, 1.72; 95% CI, 0.95–3.11) trended toward an increased risk after CAS. The authors could not rule out clinically significant differences between treatments for long-term stroke (RR, 1.24; 95% CI, 0.76–2.03) and the composite outcome of periprocedural stroke, death or myocardial infarction, or long-term ipsilateral stroke (RR, 0.92; 95% CI, 0.70–1.21).

Conclusions:

The authors concluded that the potential for increased risks of periprocedural stroke and periprocedural stroke or death with CAS suggests that CEA is the preferred option for the management of asymptomatic carotid stenosis.

Perspective:

This systematic review and meta-analysis does not rule out clinically relevant differences between CAS and CEA with respect to long-term stroke and the composite outcome of periprocedural stroke, death or myocardial infarction, or long-term ipsilateral stroke. However, the results do suggest that CAS may potentially increase the risk of any periprocedural stroke, periprocedural nondisabling stroke, and any periprocedural stroke or death. Based on these data, CEA seems to be the safer and more efficacious treatment for asymptomatic carotid artery stenosis. Additional prospective studies such as the CREST-2 trial incorporating intensive medical management alone will help further define the optimum strategy for asymptomatic carotid artery stenosis. At this time, a multidisciplinary approach to these patients is indicated.

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

Keywords: Carotid Stenosis, Endarterectomy, Carotid, Myocardial Infarction, Risk Assessment, Stents, Stroke, Treatment Outcome, Vascular Diseases


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