Carotid Artery Stenting vs Endarterectomy Across Procedural Eras : A Systematic Review and Meta-Analysis

Carotid artery stenting (CAS) and carotid endarterectomy (CEA) are established revascularization strategies, but randomized evidence has often been interpreted without accounting for major changes in CAS technique. We assessed whether the comparative 30-day safety of CAS and CEA differs when trials are stratified by early-device versus contemporary embolic-protected procedural eras.

PubMed, Embase and the Cochrane Library were searched from inception to 1 December 2025 for randomized trials of carotid revascularization in extracranial carotid stenosis. The prespecified novelty of this meta-analysis was era-based stratification according to CAS procedural standards: early-device trials (≤ 2010) versus contemporary embolic-protected CAS trials (≥ 2011), defined by operator credentialing, routine embolic protection, protocolized antiplatelet therapy and contemporary stent platforms. Direct CAS-CEA comparisons were pooled within era-specific strata; trials comparing revascularization with intensive medical therapy were analyzed separately. Fixed-effects models estimated odds ratios (ORs) with 95% confidence intervals (CIs). The primary outcome was 30-day stroke or death; secondary outcomes included peri-procedural myocardial infarction, cranial nerve injury, fatal or disabling stroke, and long-term ipsilateral stroke.

Ten randomized comparisons from nine trials including 14,211 patients were analyzed. In early-device trials, stroke or death occurred in 6.8% after CAS versus 4.4% after CEA (OR 1.72, 95% CI 1.41-2.10). In contemporary embolic-protected CAS-CEA trials, event rates were similarly low and no significant difference was observed (2.9% vs 3.1%; OR 1.29, 95% CI 0.98-1.70). CAS was associated with lower myocardial infarction (OR 0.47, 95% CI 0.31-0.72) and cranial nerve injury (OR 0.06, 95% CI 0.03-0.13). Long-term ipsilateral stroke rates were similar after CAS and CEA, with annualized rates of 0.64% and 0.60% per person-year, respectively (hazard ratio, 1.07; 95% CI, 0.81-1.41).

The excess peri-procedural stroke risk associated with CAS in early trials was not observed in contemporary randomized evidence. Contemporary CAS and CEA showed similarly low peri-procedural event rates, supporting comparable safety when CAS is performed according to current procedural standards by experienced operators. These findings suggest that CAS and CEA have comparable peri-procedural safety when performed using contemporary procedural standards, supporting individualized selection of revascularization strategies.