Carotid Artery Stenting Vs Endarterectomy for Carotid Artery Stenosis
Carotid stenting is as effective as endarterectomy in preventing recurrent stroke in symptomatic carotid stenosis but associated with a higher risk of periprocedural stroke or death than endarterectomy. Combining procedural safety and long-term efficacy in preventing recurrent stroke favours endarterectomy. Stenting for asymptomatic carotid stenosis carries a small increase in the risk of periprocedural stroke or death compared with endarterectomy. Level of evidence: "A"A Cochrane review [Abstract]2 included 22 studies with a total of 9753 patients.
- The patients with symptomatic carotid stenosis: Stenting was associated with a higher risk of periprocedural death or stroke (the primary safety outcome; OR 1.70, 95% CI 1.31 to 2.19; 10 trials, n=5396); and periprocedural death, stroke, or myocardial infarction (OR 1.43, 95% CI 1.14 to 1.80; 6 trials, n=4861). The OR for the primary safety outcome was 1.11 (95% CI 0.74 to 1.64) in patients under 70 years old and 2.23 (95% CI 1.61 to 3.08) in patents 70 years old or more (interaction p=0.007). There was a non-significant increase in periprocedural death or major or disabling stroke with stenting (OR 1.36, 95% CI 0.97 to 1.91; 7 trials, n=4983). Stenting was associated with lower risks of myocardial infarction (OR 0.47, 95% CI 0.24 to 0.94), cranial nerve palsy (OR 0.09, 95% CI 0.06 to 0.16), and access site haematoma (OR 0.32, 95% CI 0.15 to 0.68). The combination of periprocedural death or stroke or ipsilateral stroke during follow-up (the primary combined safety and efficacy outcome) favoured endarterectomy (OR 1.51, 95% CI 1.24 to 1.85; 8 trials, n=5080). The rate of ipsilateral stroke after the periprocedural period did not differ between treatments (OR 1.05, 95% CI 0.75 to 1.47).
- The patients with asymptomatic carotid stenosis:, There was a non-significant increase in periprocedural death or stroke with stenting (OR 1.72, 95% CI 1.00 to 2.97; 7 trials, n=3378). The risk of periprocedural death or stroke or ipsilateral stroke during follow-up did not differ significantly between treatments (OR 1.27, 95% CI 0.87 to 1.84; 6 trials, n=3315). Moderate or higher carotid artery restenosis (50% or greater) or occlusion during follow-up was more common after stenting (OR 2.00, 95% CI 1.12 to 3.60; n=2015), but the difference in risk of severe restenosis was not significant (70% or greater; OR 1.26, 95% CI 0.79 to 2.00).
References
- Müller MD, Lyrer P, Brown MM et al. Carotid artery stenting versus endarterectomy for treatment of carotid artery stenosis. Cochrane Database Syst Rev 2020;2():CD000515. [PubMed]