A Systematic Review and Meta-Analysis of Outcome After Repeat Revascularization for Primary Carotid Artery Restenosis

Abstract

Objective: Carotid artery restenosis can occur after both carotid artery stenting (CAS) and carotid endarterectomy (CEA). This systematic review and meta-analysis aim to determine which revascularization technique, CAS, or CEA, is superior for treating primary carotid restenosis, irrespective of the initial revascularization method used.

Design: Systematic review and meta-analysis.

Methods: MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRALs) databases were searched for eligible studies on December 19th, 2023. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was followed. Primary endpoint was the occurrence of transient ischemic attack (TIA) or any stroke. Secondary endpoints were technical success, death within 30 days, myocardial infarction (MI), local complications, cerebral hyperperfusion syndrome (CHS), cranial nerve injury (CNI), dys-/arrythmia, secondary restenosis, repeat revascularization, and long-term survival. Results were adjusted for symptomatic status and primary treatment strategy.

Results: Nineteen studies comprising 10,171 procedures in 10,041 patients were included. Baseline characteristics were comparable between groups. Main findings were (1) No difference in primary outcome; however, if adjusted for symptomatic status the rate of TIA/any stroke is higher (OR: 2.05, 95% CI: 1.29-3.27, p < 0.01) after CEA compared to CAS; (2) Significant higher rate of MI (OR: 1.85, 95% CI: 1.19-2.86, p < 0.01) after CEA; (3) Besides CNI, which appears to be commonly temporary and occurred only after CEA (7.56%, 95% CI: 4.21%-13.22%), no significant differences in other secondary endpoints were observed between groups. Long-term risk of secondary restenosis was similar between CEA compared to CAS (OR: 0.98, 95% CI: 0.39-2.49, p = 0.95); (4) Correction for the index procedure did not affect conclusions.

Conclusion: Based on limited-quality studies, mostly retrospective and nonrandomized in design, both CAS and CEA represent feasible treatment approaches for patients with primary restenosis, with comparable primary outcome between the two groups. However, based on the obtained results, CAS appears to be preferable. Patients should be critically evaluated in a multidisciplinary team and further research is desirable.Clinical ImpactThis review expands on previous studies by incorporating a larger patient cohort and more recent literature while offering new insights into restenosis. Unlike earlier research, this study uniquely evaluates first repeat revascularization outcomes (CAS and CEA) independently of the initial procedure, suggesting that patient and plaque characteristics might be more influential than the primary technique. Sensitivity analysis confirmed this, as stratification by index procedure did not alter conclusions. Although lower TIA/stroke and mortality rates were observed in CAS-treated patients, these findings were not statistically significant in the overall group. These results may help guide clinical decision-making for optimal restenosis management.

Keywords: CAS; CEA; angioplasty [MeSH]; carotid [MeSH]; carotid stenosis [MeSH]; endarterectomy; meta-analysis; reintervention; restenosis; stents [MeSH]; systematic review.