From the Center for Clinical Epidemiology, Lady Davis Institute (P.M., B.H., P.R., M.H.S., M.J.E., K.B.F.) and Division of Cardiology (M.J.E.), Jewish General Hospital, Montreal, Quebec, Canada; and Departments of Epidemiology, Biostatistics, and Occupational Health (M.J.E., K.B.F.) and Department of Medicine (K.B.F.), McGill University, Montreal, Quebec, Canada.
Stroke. 2017 Aug;48(8):2150-2157. doi: 10.1161/STROKEAHA.117.016824. Epub 2017 Jul 5.
There is no consensus on the comparative efficacy and safety of carotid artery stenting (CAS) versus carotid endarterectomy (CEA) in patients with asymptomatic carotid artery stenosis. To evaluate CAS versus CEA in asymptomatic patients, we conducted a systematic review and meta-analysis of randomized controlled trials.
We systematically searched EMBASE, PubMed, MEDLINE, and the Cochrane Library for randomized controlled trials comparing CAS to CEA in asymptomatic patients using a pre-specified protocol. Two independent reviewers identified randomized controlled trials meeting our inclusion/exclusion criteria, extracted relevant data, and assessed quality using the Cochrane risk of bias tool. Random effects models with inverse-variance weighting were used to estimate pooled risk ratios (RRs) comparing the incidences of periprocedural and long-term outcomes between CAS and CEA.
We identified 11 reports of 5 randomized controlled trials for inclusion (n=3019) asymptomatic patients. The pooled incidences of any periprocedural stroke (RR, 1.84; 95% confidence interval [CI], 0.99-3.40), periprocedural nondisabling stroke (RR, 1.95; 95% CI, 0.98-3.89), and any periprocedural stroke or death (RR, 1.72; 95% CI, 0.95-3.11) trended toward an increased risk after CAS. We could not rule out clinically significant differences between treatments for long-term stroke (RR, 1.24; 95% CI, 0.76-2.03) and the composite outcome of periprocedural stroke, death or myocardial infarction, or long-term ipsilateral stroke (RR, 0.92; 95% CI, 0.70-1.21).
Although uncertainty surrounds the long-term outcomes of CAS versus CEA, the potential for increased risks of periprocedural stroke and periprocedural stroke or death with CAS suggests that CEA is the preferred option for the management of asymptomatic carotid stenosis.
在无症状颈动脉狭窄患者中，颈动脉支架置入术（CAS）与颈动脉内膜切除术（CEA）的疗效和安全性尚无共识。为了评估无症状患者中 CAS 与 CEA 的疗效，我们对随机对照试验进行了系统评价和荟萃分析。
我们按照预先设定的方案，系统地检索了 EMBASE、PubMed、MEDLINE 和 Cochrane 图书馆中比较无症状患者中 CAS 与 CEA 的随机对照试验。两名独立的审查员根据纳入/排除标准确定符合条件的随机对照试验，提取相关数据，并使用 Cochrane 偏倚风险工具评估质量。使用逆方差加权的随机效应模型来估计 CAS 与 CEA 之间围手术期和长期结局发生率的汇总风险比（RR）。
我们纳入了 11 项研究共 5 项随机对照试验，涉及 3019 例无症状患者。CAS 后任何围手术期卒中（RR，1.84；95%置信区间 [CI]，0.99-3.40）、围手术期非致残性卒中（RR，1.95；95% CI，0.98-3.89）和任何围手术期卒中或死亡（RR，1.72；95% CI，0.95-3.11）的发生率呈增加趋势，但我们不能排除两种治疗方法在长期卒中（RR，1.24；95% CI，0.76-2.03）和围手术期卒中、死亡或心肌梗死或同侧长期卒中的复合结局（RR，0.92；95% CI，0.70-1.21）方面存在临床显著差异的可能性。
尽管 CAS 与 CEA 的长期结局存在不确定性，但 CAS 围手术期卒中风险和围手术期卒中或死亡风险增加的可能性表明，CEA 是无症状颈动脉狭窄治疗的首选方法。
