Systematic Review and Meta-Analysis of Dual-Layered Stents Versus Single-Layered Stents for Carotid Artery Stenosis

Carotid artery stenting (CAS) is widely used to treat carotid artery stenosis. However, compared with carotid endarterectomy, CAS has been associated with a higher risk of peri-procedural stroke. Recently, dual-layered stents (DLS) have demonstrated a lower risk of peri- and post-procedural stroke. We conducted a meta-analysis to evaluate the safety and efficacy of DLS in lowering stroke risk in patients undergoing CAS for carotid artery stenosis. A systematic search was performed through PubMed, Scopus, Embase, and Cochrane Library from inception until July 2024 for studies comparing DLS and single-layered stents (SLS) in patients with high-risk, lipid-rich carotid plaques. The primary outcome was peri- and postprocedural stroke. Secondary outcomes included stent occlusion, restenosis, and all-cause mortality. A random-effects meta-analysis derived risk ratios (RR) with 95% confidence intervals. Out of 395 results, 7 observational studies and 3 randomized controlled trials (RCTs) were included, totaling 2214 patients undergoing 2256 CAS procedures (1513 with DLS, 743 with SLS). Peri- and postprocedural stroke (RR: 0.33, 95% CI: 0.18-0.61; p = 0.0003; I² = 0%) was significantly lower with DLS. Stent occlusion (RR: 0.66, 95% CI: 0.20-2.24, p = 0.51, I² = 0%), restenosis (RR: 1.08, 95% CI: 0.34-3.48, p = 0.90, I² = 61%), and all-cause mortality (RR: 0.83, 95% CI: 0.17-4.11, p = 0.82, I² = 36%) were similar between stent types. Meta-regression found no significant predictors of stroke, including age, sex, hypertension, smoking, diabetes, and dyslipidemia. DLS use in CAS is associated with a lower risk of peri- and post-procedural stroke compared with SLS. This lower stroke risk should be considered in weighing CAS treatment options.