Outcomes After Intervention in Radiation-Induced Carotid Artery Stenosis: A Systematic Review and Meta-Analysis

To assess clinical outcomes after carotid endarterectomy (CEA), transfemoral carotid artery stenting (TFCAS), and transcarotid artery revascularization (TCAR) in patients with radiation induced carotid artery stenosis (RICS) utilizing a systematic review and meta-analysis.

A systematic review and meta-analysis of the literature was performed. We focused on 30-day and long-term outcomes. Study quality was assessed using the Newcastle-Ottawa Scale.

Among 36 study-arms (32 publications, 6,695 patients), the pooled 30-day stroke rate was 1.93% (95% CI 1.36-2.74) and 30-day composite outcome rate was 2.75% (95% CI 1.89-3.99). Restenosis occurred in 10.51% (95% CI 7.61-14.33) and reintervention in 6.53% (95% CI 4.29-9.83) of patients. Subgroup analysis showed numerically higher restenosis (12.0% vs 5.98%; p= 0.05) and significantly higher reintervention rates (8.06% vs 2.21%; p= 0.004) after carotid artery stenting (CAS) compared with CEA. In the comparative analysis against non-irradiated controls, perioperative outcomes were similar between groups; however, restenosis (OR 3.13, 95% CI 1.24-7.89; p= 0.028) and reintervention rates (OR 3.86, 95% CI 1.13-13.17; p= 0.022) were significantly higher in RICS patients. Time from radiotherapy to revascularization was not associated with restenosis or reintervention rates (p= 0.46 and p= 0.34, respectively).

Carotid revascularization in patients with RICS appears to be safe, with perioperative outcomes similar to those in non-irradiated patients. The main difference was in long-term follow-up, where restenosis and reintervention occur three to four times more frequently than in atherosclerotic controls. CEA also showed better long-term durability compared with CAS. These findings support close long-term surveillance in this population.