Abstract
Background Atherosclerosis of the carotid arteries is a pathophysiological process increasing the risk of stroke. Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are two recognised procedures indicated by National Institute of Clinical Excellence (NICE) guidelines aiming to reduce the risk of stroke. However, both are associated with periprocedural complications (defined as within 30 days), particularly stroke. This review aims to identify which treatment, CAS or CEA, has a lower risk of periprocedural stroke in patients with symptomatic or asymptomatic carotid artery stenosis. Methods NICE Evidence Search identified relevant UK guidelines. Search strategies combining free-text terms searched the Cochrane Database of Systematic Reviews, MEDLINE, PubMed, CINAHL, and EMBASE for systematic reviews post-2011, and RCTs from 2015 onwards. Studies were included if they contained a comparison of CEA vs CAS with regards to periprocedural risk of stroke, and if they contained novel studies not seen in the NICE guidance. English language and full-text limits were applied. Results Searches identified 202 articles. Two reviewers performed independent screening identifying 3 guidelines, 7 systematic reviews, and 1 randomised control trial eligible for inclusion. Guidelines currently advocate usage of both procedures, unlike Scottish Guidelines (SIGN) who only support CEA. Four appraised systematic reviews found a statistically significant increase in stroke probability with CAS (p 0.05). Discussion This review’s findings suggest that CAS is associated with an increased risk of periprocedural stroke when compared to CEA. Current UK guidelines by NICE and SIGN may require revisiting and take into account the new evidence not included in the original guidelines. There is a need for ongoing research as stenting technology improves over time.
Highlights
Atherosclerosis of the carotid arteries is a pathophysiological process increasing the risk of stroke
Stenting for asymptomatic stenosis can be performed by skilled clinicians under special arrangements, such as research, but Carotid endarterectomy (CEA) remains first line
Carotid angioplasty and stenting is not recommended without further evidence of its safety and efficacy above
Summary
Atherosclerosis of the carotid arteries is a pathophysiological process increasing the risk of stroke. Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are two recognised procedures indicated by the National Institute of Clinical Excellence (NICE) guidelines aiming to reduce the risk of stroke. Both are associated with periprocedural complications (defined as within 30 days), stroke. Atherosclerosis is the pathophysiological process of lipid and fibrous tissue deposition within the tunica intima of arteries, leading to plaque formation. These plaques cause luminal narrowing and may rupture, becoming a site for thrombus formation. NICE guidelines acknowledge a lack of evidence to support early stenting. [10] it can be performed at the surgeon and patient’s discretion. [11,12] Indications for carotid surgery as mentioned in the NICE TIA and Stroke Guideline CG68 can be found in Table 2. [10]
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