Endarterectomy versus stenting for the prevention of periprocedural stroke or death in patients with symptomatic or asymptomatic carotid stenosis: a meta-analysis of 10 randomized trials

Abstract

BackgroundThe incidence of stroke or death in carotid endarterectomy (CEA) versus carotid artery stenting (CAS) cannot be estimated accurately. We aimed to compare periprocedural stroke or death in patients with symptomatic or asymptomatic carotid artery stenosis (CS) treated with CEA versus CAS.MethodsTen randomized trials (with ≥100 randomized patients per trial) compared the relative effectiveness of CAS and CEA for the prevention of stroke or death.ResultsIn the symptomatic group during the periprocedural period, the results showed that the risk of death or any stroke [risk ratio (RR): 0.627; 95% CI: 0.497–0.792; P<0.001] and the risk of any stroke (RR: 0.654; 95% CI: 0.522–0.820; P<0.001) were significantly greater with CAS than with CEA. The difference in the risk of periprocedural stroke was mostly attributed to nondisabling stroke (RR: 0.407; 95% CI: 0.264–0.627; P<0.001), which was driven especially by ipsilateral ischemic stroke (RR: 0.649; 95% CI: 0.494–0.851; P=0.002) and bradycardia or hypotension (RR: 0.105; 95% CI: 0.051–0.217; P<0.001). However, we found that the CEA group had a higher rate of myocardial infarction than the CAS group (RR: 2.496; P=0.025). Meanwhile, ipsilateral stenosis >70% increased the incidence of periprocedural death or stroke for post-CEA patients (RR: 2.166, 95% CI: 1.112 to 4.220, P=0.023), but no risk factors were identified for post-CAS. Regarding the asymptomatic group, the results demonstrated that patients randomized to CEA had a significantly reduced risk of periprocedural stroke (RR: 0.518; 95% CI: 0.281–0.954; P=0.035), which seems to be driven by periprocedural minor stroke (RR: 0.482; 95% CI: 0.231–0.982; P=0.046).ConclusionsAmong patients with symptomatic CS, CEA was associated with reduced rates of periprocedural stroke and periprocedural nondisabling stroke. Among patients with asymptomatic CS, the rates of minor stroke and stroke in general were higher with stenting than with CEA. Based on the current data, CEA is more beneficial than CAS for 30-day stroke prevention.