Management of Patients with Internal Carotid Artery Near-total Occlusion: An Updated Meta-analysis

The decision for revascularization in patients with near-total internal carotid artery (ICA) occlusion still remains controversial. We undertook an extensive review of the literature and conducted a meta-analysis aiming to investigate the appropriate therapeutic approach for patients with near-total ICA occlusion.

A multiple electronic health database search was performed on all articles published up to December 2014. All available data were analyzed giving emphasis on the applied therapeutic approach (best medical therapy [BMT], carotid endarterectomy [CEA], and carotid artery stenting [CAS]), whereas the main endpoints of the meta-analysis were transient ischemic attack (TIA), stroke, stroke-related death, myocardial infarction (MI), major adverse event (MAE), overall mortality, and restenosis.

Five articles on BMT and CEA, 8 articles on CEA, and 11 articles on CAS were deemed eligible. A statistically significant difference was recorded in pooled stroke incidence rates (IRs) per 100 patient-years (p-ys) of BMT (IR = 6.19) compared with CEA (IR = 2.24, P = 0.002) and CAS (IR = 1.64, P < 0.001) studies. No statistically significant differences were recorded in pooled IRs per 100 p-ys between CEA and CAS, concerning TIA (P = 0.96), stroke (P = 0.44), stroke-related death (P = 0.30), and MAE (P = 0.99), whereas a borderline significance was recorded concerning overall mortality (P = 0.08) and restenosis (P = 0.08). No nominally significant effects were demonstrated with respect to almost all the studied potential modifiers in meta-regression analysis among the eligible studies.

An intervention is probably indicated for patients with near-total ICA occlusion. The results of our study underline the need for including patients with near-total ICA occlusion in future randomized controlled trials. Meanwhile, the treatment of these patients should be individualized.