Carotid artery stenting versus carotid endarterectomy: updated meta-analysis, metaregression and trial sequential analysis of short-term and intermediate-to long-term outcomes of randomized trials.

INTRODUCTION

To compare carotid artery stenting (CAS) versus carotid endarterectomy (CEA) in the treatment of carotid stenosis, including two recently published, prospective, randomized trials of these therapies.

EVIDENCE ACQUISITION

A multiple electronic health database search on all randomized trials describing CAS compared with CEA in patients with symptomatic or asymptomatic carotid artery stenosis was performed. Primary outcomes were death, stroke, and myocardial infarction.

EVIDENCE SYNTHESIS

Carotid artery stenting as compared with CEA was associated with a 61% increase in the risk of periprocedural death or stroke (Peto OR, 1.609; 95% confidence interval [CI]: 1.193-2.170; P=0.002). The trial sequential monitoring boundary was crossed by the cumulative Z-curve, suggesting firm evidence for at least a 20% relative risk increase of periprocedural death or stroke and any stroke compared with CEA. Carotid artery stenting as compared with CEA was associated with a 42% increase in the risk for the composite of periprocedural stroke or death plus ipsilateral stroke thereafter (Peto OR, 1.417; 95% CI: 1.074-1.870; P=0.0014).

CONCLUSIONS

In this largest and most comprehensive meta-analysis to date using outcomes that are standard in contemporary studies, CAS was associated with an increased risk of both periprocedural and intermediate- to long-term outcomes.