Comprehensive Evaluation and Management Strategies for Asymptomatic Carotid Artery Stenosis: A Critical Review and...

Management of asymptomatic carotid artery stenosis (ACAS) is variable, including carotid endarterectomy (CEA), carotid artery stenting (CAS), and best medical treatment (BMT). The contemporary risk-benefit profiles of invasive versus medical therapies remain unclear.

A systematic review and network meta-analyses were conducted using data from randomized controlled trials (RCTs) including patients with ≥50% ACAS. Outcomes assessed were 30-day stroke and mortality, long-term stroke (30 days-10 years), and stroke subtypes (major, minor, ipsilateral, contralateral). Traditional (pre-2000) and modern (post-2000) BMT were compared to assess temporal improvements in medical therapy.

Eleven RCTs (14,295 randomized participants) were identified; 9 trials contributed extractable asymptomatic data (12,320 participants) to at least one endpoint-specific network meta-analysis. Compared with CEA, BMT was associated with lower odds of 30-day stroke (odds ratio [OR]: 0.29, 95% confidence interval [CI]: 0.16-0.55) and 30-day stroke/death (OR: 0.26, 95% CI: 0.15-0.44). CAS showed higher point estimates for early neurologic events versus CEA, but precision was limited for composites (e.g., 30-day stroke/death OR: 1.71, 95% CI: 0.97-2.99). For nonprocedural long-term stroke, CEA was associated with lower odds than BMT (BMT versus CEA OR: 2.22, 95% CI: 1.70-2.90), whereas CAS and CEA were similar (CAS versus CEA OR: 1.09, 95% CI: 0.85-1.41). In the post-2000 subset, ipsilateral stroke after 30 days numerically favored CAS versus CEA (OR: 0.84, 95% CI: 0.32-2.19) but remained imprecise. Surface Under the Cumulative Ranking were used as supportive summaries and interpreted in the context of effect sizes and uncertainty.

In RCT evidence for ACAS, BMT was associated with the most favorable 30-day profile, while CEA reduced nonprocedural long-term stroke versus BMT. CAS may carry higher early neurologic risk, with long-term outcomes largely comparable to CEA; a possible modern-era advantage for ipsilateral stroke is hypothesis-generating given wide CIs and potential misclassification of "modern" therapy around the year-2000 cut point. Contemporary decision-making should prioritize absolute risks, patient-specific procedural risk, and sustained adherence to intensive medical therapy.