Short term and intermediate term comparison of endarterectomy versus stenting for carotid artery stenosis: systematic review and meta-analysis of randomised controlled clinical trials

Abstract

Objective: To evaluate the relative short term safety and intermediate term efficacy of carotid endarterectomy versus carotid artery stenting.

Design: Systematic review and meta-analysis.

Data sources: BIOSIS, Embase, Medline, the Cochrane central register of controlled trials, International Pharmaceutical Abstracts database, ISI Web of Science, and Google scholar and bibliographies, from 1 January 1990 to 25 July 2009.

Study selection: Randomised controlled trials comparing carotid endarterectomy with carotid artery stenting in patients with carotid artery stenosis with or without symptoms.

Data extraction: Primary end point was a composite of mortality or stroke. Secondary end points were death, stroke, myocardial infarction, or facial neuropathy (as individual end points), and mortality or disabling stroke (as a composite end point).

Data synthesis: 11 trials were included (4796 patients); 10 reported on short term outcomes (n=4709) and nine on intermediate term outcomes (1-4 years). The periprocedural risk of mortality or stroke was lower for carotid endarterectomy (odds ratio 0.67, 95% confidence interval 0.47 to 0.95; P=0.025) than for carotid stenting, mainly because of a decreased risk of stroke (0.65, 0.43 to 1.00; P=0.049), whereas the risk of death (1.14, 0.56 to 2.31; P=0.727) and the composite end point mortality or disabling stroke (0.74, 0.53 to 1.05; P=0.088) did not differ significantly. The odds of periprocedural myocardial infarction (2.69, 1.06 to 6.79; P=0.036) or cranial nerve injury (10.2, 4.0 to 26.1; P<0.001) was higher in the carotid endarterectomy group than in the carotid stenting group. In the intermediate term, the two treatments did not differ significantly for stroke or death (hazard ratio 0.90, 95% confidence interval 0.74 to 1.1; P=0.314).

Conclusions: Carotid endarterectomy was found to be superior to carotid artery stenting for short term outcomes but the difference was not significant for intermediate term outcomes; this difference was mainly driven by non-disabling stroke. Significantly fewer cranial nerve injuries and myocardial infarctions occurred with carotid artery stenting.

Fig 1 Outline of search and selection strategy

Fig 2 Forest plot of odds ratios of risk for composite of stroke or death within 30 days of carotid endarterectomy versus carotid artery stenting. ICSS also included myocardial infarctions (three for stenting, four for endarterectomy) in this end point. See footnote to table for full title of studies

Fig 3 Forest plot of odds ratios of 30 day risk for stroke or death (individual end points) within 30 days of carotid endarterectomy versus carotid artery stenting. ICSS was not included in this analysis for death because overall mortality data based on an intention to treat analysis were not available See footnote to table for full title of studies

Fig 4 Forest plot of odds ratios of 30 day risk for myocardial infarction for carotid endarterectomy versus carotid artery stenting. See footnote to table for full title of studies

Fig 5 Forest plot of odds ratio of periprocedural (30 day) cranial nerve injuries for carotid endarterectomy versus carotid artery stenting. See footnote to table for full title of studies

Fig 6 Forest plot of hazard ratio of intermediate term risk for composite of stroke or death

Fig 7 Forest plot of odds ratios of intermediate term risk for composite of stroke or death as binary outcomes, without considering time interval between intervention and event (Wallstent trial used an endpoint definition of “ipsilateral stroke, procedure-related death, or vascular death within 1 year”)