Carotid Artery Endarterectomy versus Carotid Artery Stenting for Restenosis After Carotid Artery Endarterectomy: A Systematic Review and Meta-Analysis

Abstract

Objective: Carotid artery restenosis may occur after ipsilateral carotid endarterectomy (CEA). The aim of this study was to determine whether carotid artery stenting (CAS) or redo CEA is the optimal treatment for postendarterectomy carotid restenosis.

Methods: Eligible studies for meta-analysis were identified through a search of PubMed, Scopus, and Cochrane up to July 20, 2017. A meta-analysis was conducted with the use of random effects modeling. I² was used to assess for heterogeneity.

Results: Thirteen studies comprising 4163 patients were included. Risk for any type of cranial nerve injury was higher in the redo CEA group (odds ratio = 13.61; 95% confidence interval, 5.43-34.16; I² = 3.3%). Periprocedural and/or short-term (within 30 days) stroke, transient ischemic attack, myocardial infarction, temporary cranial nerve injury, and death rates were similar between the 2 revascularization approaches. During median follow-up of 28 months, CAS was associated with significantly lower risk for long-term recurrent carotid artery restenosis when defined as stenosis >60% (odds ratio = 2.16; 95% confidence interval, 1.13-4.12; I² = 0%) or >70% (odds ratio = 2.31; 95% confidence interval, 1.13-4.72; I² = 0%). No difference was identified in long-term target lesion revascularization rates between redo CEA and CAS.

Conclusions: Patients with carotid restenosis after CEA can safely undergo both CAS and CEA with similar risks of periprocedural stroke, transient ischemic attack, myocardial infarction, and death. However, patients treated with CAS have a lower risk for a new restenosis and periprocedural cranial nerve injury.

Keywords: Carotid artery endarterectomy; Carotid artery stenting; Recurrent stenosis; Restenosis.