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Review
. 2017 Jul 14;12(7):e0180804.
doi: 10.1371/journal.pone.0180804. eCollection 2017.

Long-term efficacy and safety of carotid artery stenting versus endarterectomy: A meta-analysis of randomized controlled trials

Yang Li  1 , Jing-Jing Yang  2 , Su-Hui Zhu  1 , Biao Xu  1 , Lian Wang  1
Affiliations
Review

Long-term efficacy and safety of carotid artery stenting versus endarterectomy: A meta-analysis of randomized controlled trials

Yang Li et al. PLoS One. .

Erratum in

Abstract

Background: Many recent trials have investigated the long-term efficacy and safety of endarterectomy versus stenting in treating patients with carotid artery stenosis. We aimed to determine the long-term comparative efficacy and safety of both procedures by pooling this evidence in a meta-analysis.

Methods: We searched PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials for studies published until May 6, 2016. Randomized controlled trials, which reported outcomes of interest with a median follow-up of at least 4-year, were included.

Results: Eight trials involving 7005 patients and 41824 patient-years of follow-up were included. In terms of the periprocedural outcomes, stenting was associated with a lower risk of myocardial infarction (OR: 0.51; 95% CI: 0.33 to 0.80; P = 0.003) but a higher risk of death or stroke (the composite endpoint, OR: 1.76; 95% CI: 1.38 to 2.25; P < 0.0001), a result that was primarily driven by minor stroke (OR: 2.19; 95% CI: 1.59 to 3.01; P < 0.0001), less so by periprocedural death (OR: 1.68; 95% CI: 0.82 to 3.44; P = 0.16) and major stroke (OR: 1.41; 95% CI: 0.95 to 2.09; P = 0.09). In terms of the long-term outcomes, stenting was associated with a higher risk of stroke (OR 1.45; 95% CI: 1.22 to 1.73; P < 0.0001) and the composite outcome of death or stroke (OR 1.25; 95% CI: 1.05 to 1.48; P = 0.01). No difference was found in long-term all-cause mortality between stenting and endarterectomy (OR: 1.09; 95% CI: 0.95 to 1.26; P = 0.21) and restenosis (OR: 1.48 (95% CI: 0.93 to 2.35; P = 0.10). No evidence of significant heterogeneity was found in any of the analyses.

Conclusions: Carotid endarterectomy was found to be superior to stenting for short- and long-term outcomes, although endarterectomy was associated with a higher risk of periprocedural myocardial infarction. Carotid endarterectomy should be offered as the first choice for carotid stenosis at present, however, more evidence is needed because rapid progress in concurrent devices and medical treatments is being made.

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Conflict of interest statement

Competing Interests: The authors have declared that no competing interests exist.

Figures

Fig 1
Fig 1. The cumulative incidence of the composite outcome of death or stroke.
CAS: Carotid Artery Stenting; CEA: Carotid Endarterectomy; ACT I: Asymptomatic Carotid Trial I; CREST: Carotid Revascularization Endarterectomy vs. Stenting Trial; ICSS: International Carotid Stenting Study; EVA-3S: Endarterectomy Versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis; BACASS: Basel Carotid Artery Stent Study; CAVATAS: Carotid and Vertebral Artery Transluminal Angioplasty Study; and Odd Ratio: adopted per 100 patient-years odd ratio.
Fig 2
Fig 2. The cumulative incidence of stroke.
CAS: Carotid Artery Stenting; CEA: Carotid Endarterectomy; ACT I: Asymptomatic Carotid Trial I; CREST: Carotid Revascularization Endarterectomy vs. Stenting Trial; ICSS: International Carotid Stenting Study; EVA-3S: Endarterectomy Versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis; CAVATAS: Carotid and Vertebral Artery Transluminal Angioplasty Study; Odd Ratio: adopted per 100 patient-years odd ratio.
Fig 3
Fig 3. The cumulative incidence of long-term all-cause mortality.
CAS: Carotid Artery Stenting; CEA: Carotid Endarterectomy; ACT I: Asymptomatic Carotid Trial I; ICSS: International Carotid Stenting Study; EVA-3S: Endarterectomy Versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis; CAVATAS: Carotid and Vertebral Artery Transluminal Angioplasty Study; Odd Ratio: adopted per 100 PYs odd ratio.
Fig 4
Fig 4. The cumulative incidence of the composite endpoint of death, ipsilateral stroke or periprocedural stroke.
CAS: Carotid Artery Stenting; CEA: Carotid Endarterectomy; ACT I: Asymptomatic Carotid Trial I; CREST: Carotid Revascularization Endarterectomy vs. Stenting Trial; ICSS: International Carotid Stenting Study; EVA-3S: Endarterectomy Versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis; BACASS: Basel Carotid Artery Stent Study; CAVATAS: Carotid and Vertebral Artery Transluminal Angioplasty Study; Odd Ratio: adopted per 100 patient-years odd ratio.
Fig 5
Fig 5. The cumulative incidence of restenosis.
CAS: Carotid Artery Stenting; CEA: Carotid Endarterectomy; CREST: Carotid Revascularization Endarterectomy vs. Stenting Trial; ICSS: International Carotid Stenting Study; EVA-3S: Endarterectomy Versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis; CAVATAS: Carotid and Vertebral Artery Transluminal Angioplasty Study; Odd Ratio: adopted per 100 patient-years odd ratio.
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