Abstract 14274: Management of Severe Asymptomatic Carotid Stenosis, Best Medical versus Stenting versus Endarterectomy, a Network Meta Analysis of Randomized Controlled Trials

Abstract

Background: We conducted a network meta-analysis to investigate the efficacy and safety of best medical therapy (BMT) versus carotid artery stenting (CAS) versus carotid endarterectomy (CEA) in patients with severe asymptomatic carotid stenosis. Methods: We systematically searched Web of Science, SCOPUS, EMBASE, PubMed, and Cochrane Central till March 1 st , 2023, to include any randomized control trial (RCT) that assesses the efficacy of BMT, CAS, or CEA in the management of severe asymptomatic carotid stenosis. A network meta-analysis was conducted using R software pooling dichotomous outcomes using risk ratio (RR) and 95% confidence interval (CI). Results: Eight RCTs with 10,094 patients were included. Compared to BMT, both CAS and CEA showed a statistically significant higher risk of the 30 days composite (stroke, myocardial infarction (MI), and mortality) (RR: 4.37 [95% CI 2.35 - 8.11]) (RR: 4.04 [95% CI 2.08 - 7.85]), respectively; mortality (RR: 6.93 [95% CI 1.60 - 29.98]) (RR: 8.12 [95% CI 1.88 - 35.16]), respectively; MI with (RR: 16.03 [95% CI 1.96 - 26.14]) (RR: 27.51 [95% CI 1.65 - 45.46]), respectively; and stroke (RR: 3.42 [95% CI 1.70 - 6.88]) (RR: 2.48 [95% CI 1.23 - 4.99]), respectively. However, both CAS and CEA did not show statistically significant differences between BMT five-year mortality and MI. Finally, CEA showed a statistically significant lower risk of 5-year restenosis with (RR: 0.38 [95% CI 0.12 - 0.88]) and stroke (RR: 0.27 [95% CI 0.22 - 0.98]) compared to BMT. Conclusion: BMT for severe asymptomatic carotid stenosis holds an equal efficacy compared to CSA and CEA, yet an even lower risk regarding short-term outcomes. However, CEA shows a lower risk compared to BMT and CSA in terms of long-term (five-year) stroke and restenosis. Further research is still warranted to clarify which patients can benefit most from invasive strategies and to furtherly investigate BMT due to the currently limited evidence.