Objective: Carotid angioplasty and stenting (CAS) has challenged carotid endarterectomy (CEA) as the therapy of choice for carotid disease. This meta-analysis aims at summarizing the most current body of evidence. Methods: All prospective, controlled clinical trials comparing CEA versus CAS were included. The outcome measures of interest were relative risk (RR) of 30-day stroke, 30-day stroke/death, long-term risk of stroke, and risk of restenosis. Results: The RR of 30-day stroke for CAS was 1.6 times that of CEA (RR 1.6; 95%CI 1.2-2.0, P = .001). The 30-day RR of stroke/death was 1.5 times higher for CAS (RR 1.5; 95%CI 1.1-2.1, P = .008). There was a higher risk of long-term stroke (RR 1.2; 95%CI 1.0-1.5, P = .043). The risk of restenosis was twice for CAS (RR 1.8; 95%CI 1.1-3.1, P = .04). Conclusion: The 30-day RR of stroke, stroke/death, long-term risk of stroke, and risk of restenosis are consistently higher for carotid artery stenting (CAS).
Mayberg MR, Wilson SE, Yatsu F., et al. Carotid endarterectomy and prevention of cerebral ischemia in symptomatic carotid stenosis. Veterans Affairs Cooperative Studies Program 309 Trialist Group. JAMA. 1991;266(23):3289-3294.
2.
Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST). Lancet. 1998;351(9113):1379-1387.
3.
Endarterectomy for asymptomatic carotid artery stenosis. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. JAMA. 1995;273(18):1421-1428.
4.
MRC European Carotid Surgery Trial: interim results for symptomatic patients with severe (70-99%) or with mild (0-29%) carotid stenosis. European Carotid Surgery Trialists’ Collaborative Group. Lancet. 1991;337(8752):1235-1243.
5.
Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med. 1991;325(7):445-453.
6.
Halliday A., Mansfield A., Marro J., et al. Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomised controlled trial. Lancet. 2004;363(9420):1491-1502.
7.
Naylor AR, Bolia A., Abbott RJ, et al. Randomized study of carotid angioplasty and stenting versus carotid endarterectomy: a stopped trial. J Vasc Surg. 1998;28(2):326-334.
8.
Link J., Manke C., Rosin L., et al. [Carotid endarterectomy and carotid stenting A pilot study of a prospective, randomized and controlled comparison]. Radiologe . 2000;40(9):813-820.
9.
Brooks WH, McClure RR, Jones MR, Coleman TC, Breathitt L.Carotid angioplasty and stenting versus carotid endarterectomy: randomized trial in a community hospital. J Am Coll Cardiol. 2001;38(6):1589-1595.
10.
Endovascular versus surgical treatment in patients with carotid stenosis in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS): a randomised trial. Lancet. 2001 ; 357(9270):1729-1737.
11.
Alberts M.Results of a multicenter prospective randomized control trial of carotid artery stenting vs carotid endarterectomy [Abstract]. Stroke. 2001;32:325.
12.
Brooks WH, McClure RR, Jones MR, Coleman TL, Breathitt L.Carotid angioplasty and stenting versus carotid endarterectomy for treatment of asymptomatic carotid stenosis: a randomized trial in a community hospital . Neurosurgery. 2004;54(2):318-324; discussion 324-315.
13.
Mas JL, Chatellier G., Beyssen B., et al. Endarterectomy versus stenting in patients with symptomatic severe carotid stenosis. N Engl J Med. 2006 ;355(16):1660-1671.
14.
Yadav JS, Wholey MH, Kuntz RE, et al. Protected carotid-artery stenting versus endarterectomy in high-risk patients. N Engl J Med. 2004;351(15):1493-1501.
15.
Ringleb PA, Allenberg J., Bruckmann H., et al. 30 day results from the SPACE trial of stent-protected angioplasty versus carotid endarterectomy in symptomatic patients: a randomised non-inferiority trial. Lancet. 2006;368(9543):1239-1247.
16.
Brown MMSafety results of ICSS study. Paper presented at: European Stoke Conference; May 2009, 2009; Stockholm.
Roh HG, Byun HS, Ryoo JW, et al. Prospective analysis of cerebral infarction after carotid endarterectomy and carotid artery stent placement by using diffusion-weighted imaging. AJNR Am J Neuroradiol. 2005;26(2):376-384.
19.
Becquemin JP , Ben E.l Kadi H., Desgranges P., Kobeiter H.Carotid stenting versus carotid surgery: a prospective cohort study. J Endovasc Ther. 2003;10(4):687-694.
20.
Carotid revascularization using endarterectomy or stenting systems (CARESS): phase I clinical trial. J Endovasc Ther . 2003; 10(6):1021-1030.
21.
Iihara K., Murao K., Sakai N., Yamada N., Nagata I., Miyamoto S.Outcome of carotid endarterectomy and stent insertion based on grading of carotid endarterectomy risk: a 7-year prospective study. J Neurosurg. 2006;105(4):546-554.
22.
Featherstone RL, Brown MM, Coward LJInternational carotid stenting study: protocol for a randomised clinical trial comparing carotid stenting with endarterectomy in symptomatic carotid artery stenosis. Cerebrovasc Dis. 2004;18(1):69-74.
23.
Theiss W., Hermanek P., Mathias K., et al. Predictors of death and stroke after carotid angioplasty and stenting: a subgroup analysis of the Pro-CAS data. Stroke . 2008;39(8):2325-2330.
24.
Gray WA, Yadav JS, Verta P., et al. The CAPTURE registry: results of carotid stenting with embolic protection in the post approval setting. Catheter Cardiovasc Interv. 2007;69(3): 341-348.
25.
Sidawy AN, Zwolak RM, White RA, Siami FS, Schermerhorn ML, Sicard GARisk-adjusted 30-day outcomes of carotid stenting and endarterectomy: results from the SVS Vascular Registry. J Vasc Surg.2009;49(1):71-79.
26.
Brott TG, Hobson RW, 2nd, Howard G., et al. Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med. 363(1):11-23.
27.
Coward LJ, Featherstone RL, Brown MMSafety and efficacy of endovascular treatment of carotid artery stenosis compared with carotid endarterectomy: a Cochrane systematic review of the randomized evidence. Stroke. 2005;36(4):905-911.
28.
Qureshi AI, Kirmani JF, Divani AA, Hobson RW, 2nd.Carotid angioplasty with or without stent placement versus carotid endarterectomy for treatment of carotid stenosis: a meta-analysis. Neurosurgery . 2005;56(6):1171-1179; discussion 1179-1181.
29.
Paraskevas KI , Mikhailidis DP, Veith FJCarotid artery stenting may be losing the battle against carotid endarterectomy for the management of symptomatic carotid artery stenosis, but the jury is still out. Vascular.2009;17(4):183-189.
30.
Ringleb PA, Chatellier G., Hacke W., et al. Safety of endovascular treatment of carotid artery stenosis compared with surgical treatment: a meta-analysis. J Vasc Surg. 2008;47(2):350-355.
31.
Brahmanandam S., Ding EL, Conte MS, Belkin M., Nguyen LLClinical results of carotid artery stenting compared with carotid endarterectomy. J Vasc Surg. 2008;47(2):343-349.
32.
Mas JL, Trinquart L., Leys D., et al. Endarterectomy Versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis (EVA-3S) trial: results up to 4 years from a randomised, multi-centre trial. Lancet Neurol. 2008;7(10):885-892.
33.
Eckstein HH , Ringleb P., Allenberg JR, et al. Results of the Stent-Protected Angioplasty versus Carotid Endarterectomy (SPACE) study to treat symptomatic stenoses at 2 years: a multinational, prospective, randomised trial. Lancet Neurol. 2008;7(10): 893-902.
34.
Gurm HS, Yadav JS, Fayad P., et al. Long-term results of carotid stenting versus endarterectomy in high-risk patients. N Engl J Med. 2008;358(15):1572-1579.
35.
Ederle J., Bonati LH, Dobson J., et al. Endovascular treatment with angioplasty or stenting versus endarterectomy in patients with carotid artery stenosis in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS): long-term follow-up of a randomised trial. Lancet Neurol.2009;8(10):898-907.
36.
McCabe DJ, Pereira AC, Clifton A., Bland JM, Brown MMRestenosis after carotid angioplasty, stenting, or endarterectomy in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS). Stroke. 2005;36(2):281-286.
37.
Carotid Revascularization Using Endarterectomy or Stenting Systems (CaRESS) phase I clinical trial: 1-year results. J Vasc Surg. 2005;42(2):213-219.
38.
Yadav JSCarotid stenting in high-risk patients: design and rationale of the SAPPHIRE trial. Cleve Clin J Med. 2004; 71(Suppl 1):S45-S46.
39.
Reiff T., Stingele R., Eckstein HH, et al. Stent-protected angioplasty in asymptomatic carotid artery stenosis vs. endarterectomy: SPACE2-a three-arm randomised-controlled clinical trial . Int J Stroke.2009;4(4):294-299.
40.
Ricotta JJ, 2nd, Malgor RDA review of the trials comparing carotid endarterectomy and carotid angioplasty and stenting. Perspect Vasc Surg Endovasc Ther. 2008;20(3):299-308.
41.
Rothwell PM , Eliasziw M., Gutnikov SA, et al. Analysis of pooled data from the randomised controlled trials of endarterectomy for symptomatic carotid stenosis. Lancet. 2003;361(9352): 107-116.
