Carotid artery stenting vs carotid endarterectomy: meta-analysis and diversity-adjusted trial sequential analysis of
Sripal Bangalore1, Sunil Kumar, Jørn Wetterslev
1New York University School of Medicine, New York, USA.
Insights
Carotid artery stenting (CAS) increases risks for stroke and death compared to carotid endarterectomy (CEA), despite reducing heart attacks and nerve injuries. Further research is needed to determine optimal patient selection for each procedure.
Area of Science:
- Vascular Surgery
- Interventional Cardiology
- Neurosurgery
Background:
- The comparative effectiveness of carotid artery stenting (CAS) versus carotid endarterectomy (CEA) remains debated.
- Recent clinical trials suggest a potential increase in harm associated with CAS.
Purpose of the Study:
- To conduct a comprehensive meta-analysis evaluating the periprocedural and long-term benefits and harms of CAS compared to CEA.
- To synthesize evidence from randomized clinical trials to inform clinical decision-making.
Main Methods:
- Systematic search of PubMed, EMBASE, and Cochrane Central Register of Controlled Trials for randomized clinical trials up to June 2010.
- Extraction of periprocedural (≤30-day) and intermediate-to-long-term outcomes, including death, myocardial infarction (MI), and stroke.
- Data extraction by two independent reviewers, focusing on baseline characteristics, procedural details, and outcomes.
Main Results:
- Analysis of 13 randomized clinical trials involving 7477 participants.
- CAS was associated with increased periprocedural risks of death, MI, or stroke (OR=1.31) and any stroke (67% increase).
- CAS demonstrated reduced risks of periprocedural MI (55% reduction) and cranial nerve injury (85% reduction), with firm evidence for increased stroke risk and reduced MI risk.
Conclusions:
- This meta-analysis indicates CAS is linked to higher periprocedural and long-term risks of adverse outcomes compared to CEA.
- CAS offers benefits in reducing periprocedural MI and cranial nerve injury.
- Urgent strategies are required to identify patient subgroups who would benefit most from CAS versus CEA.
Background:
The role of carotid artery stenting (CAS) when compared with carotid endarterectomy (CEA) is controversial, with recent trials showing an increased risk of harm with CAS.
Objective:
To evaluate the periprocedural and intermediate to long-term benefits and harms of CAS compared with CEA.
Data Sources And Study Selection:
PubMed, EMBASE, and Cochrane Central Register of Controlled Trials searches for randomized clinical trials until June 2010 of CAS compared with CEA for carotid artery disease. Periprocedural (≤30-day) outcomes (death, myocardial infarction [MI], or stroke; death or any stroke; any stroke; and MI) and intermediate to long-term outcomes (outcomes as in the Stenting and Angioplasty With Protection in Patients at High Risk for Endarterectomy [SAPPHIRE] trial: composite of periprocedural death, MI, or stroke plus ipsilateral stroke or death thereafter; periprocedural death or stroke plus ipsilateral stroke thereafter; death or any stroke; and any stroke) were evaluated.
Data Extraction:
Two of us independently extracted data in duplicate. Baseline characteristics, inclusion and exclusion criteria, use of an embolic protection device, US vs non-US study, and the earlier-mentioned outcomes of interest were extracted from each trial.
Data Synthesis:
We identified 13 randomized clinical trials randomizing 7477 participants. Carotid artery stenting was associated with an increased risk of periprocedural outcomes of death, MI, or stroke (odds ratio = 1.31; 95% confidence interval, 1.08-1.59), 65% and 67% increases in death or stroke and any stroke, respectively, but with 55% and 85% reductions in the risk of MI and cranial nerve injury, respectively, when compared with CEA. The trial sequential monitoring boundary was crossed by the cumulative z curve, suggesting firm evidence for at least a 20% relative risk increase of periprocedural death or stroke and any stroke and at least a 15% reduction in MI with CAS compared with CEA. Similarly, CAS was associated with 19%, 38%, 24%, and 48% increases in the intermediate to long-term outcomes of SAPPHIRE-like outcome, periprocedural death or stroke and ipsilateral stroke thereafter, death or any stroke, and any stroke, respectively. The trial sequential monitoring boundary was crossed by the cumulative z curve, suggesting firm evidence for at least a 20% relative risk increase of any stroke.
Conclusions:
In this largest and most comprehensive meta-analysis to date using outcomes that are standard in contemporary studies, CAS was associated with an increased risk of both periprocedural and intermediate to long-term outcomes, but with a reduction in periprocedural MI and cranial nerve injury. Strategies are urgently needed to identify patients who are best served by CAS vs CEA.
