Safety of Stenting and Endarterectomy for Asymptomatic Carotid Artery Stenosis: A Meta-Analysis of Randomised Controlled Trials

Abstract

Objective/background: A meta-analysis of recently published randomised controlled trials (RCTs) was performed to evaluate the safety of carotid artery stenting (CAS) versus carotid endarterectomy (CEA) for asymptomatic carotid stenosis with average risk.

Methods: The MEDLINE, Embase, and Cochrane Library databases were systematically searched for RCTs that compared CAS with CEA for asymptomatic carotid stenosis. These publications reported clinical outcomes after revascularisation in patients with asymptomatic carotid stenosis during their primary intervention. Trials published in English were searched for on 31 May 2017. End points (composite of ipsilateral stroke, any stroke, major stroke, minor stroke, myocardial infarction [MI], and death during the post-procedural period) were extracted from the publications by two reviewers. The pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for peri-operative outcomes following CAS and CEA using a fixed effects model.

Results: Five studies involving 3901 patients (1585 with CEA; 2316 with CAS) were included in the meta-analysis. The risk of any stroke during the peri-procedural period was significantly lower in patients who underwent CEA than CAS (OR 0.53; 95% CI 0.29-0.96). The difference between CAS and CEA in the rate of stroke could be driven by minor stroke (OR 0.50; 95% CI 0.25-1.00). The risk of death, major stroke, ipsilateral stroke, and MI were not significantly different between the two interventions (peri-procedural death: OR 1.49 [95% CI 0.26-8.68]; peri-procedural major stroke: OR 0.69 [95% CI 0.20-2.35]; peri-procedural ipsilateral stroke: OR 0.63 [95% CI 0.27-1.47]; peri-procedural MI: OR 1.75 [95% CI 0.84-3.65]). No robust conclusion could be drawn regarding mid to long-term complications because of the heterogeneity of the reported data. The different outcomes precluded any further analysis being conducted.

Conclusion: Among patients with asymptomatic carotid stenosis, stenting has a significantly higher rate of any peri-procedural stroke and peri-procedural minor stroke than CEA, and similar risk of peri-procedural major stroke, peri-procedural ipsilateral stroke, or MI.

Keywords: Asymptomatic carotid stenosis; Endarterectomy; Meta-analysis; Stenting.