Meta-analysis of stenting vs endarterectomy for carotid stenosis

January 01, 0001

Meta-analysis of stenting vs endarterectomy for carotid stenosis

The role of carotid artery stenting (CAS) when compared with carotid endarterectomy (CEA) is controversial, with recent trials showing an increased risk of harm with CAS. These authors from the US and Denmark conducted a meta-analysis of randomized controlled trials to evaluate the periprocedural and intermediate to long-term benefits and harms of CAS compared with CEA.

They found: "We identified 13 randomized clinical trials randomizing 7477 participants. Carotid artery stenting was associated with an increased risk of periprocedural outcomes of death, MI, or stroke (odds ratio = 1.31), 65% and 67% increases in death or stroke and any stroke, respectively, but with 55% and 85% reductions in the risk of MI and cranial nerve injury, respectively, when compared with CEA. 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 and at least a 15% reduction in MI with CAS compared with CEA. Similarly, CAS was associated with 19%, 38%, 24%, and 48% increases in the intermediate to long-term outcomes of SAPPHIRE-like outcome, periprocedural death or stroke and ipsilateral stroke thereafter, death or any stroke, and any stroke, respectively. The trial sequential monitoring boundary was crossed by the cumulative z curve, suggesting firm evidence for at least a 20% relative risk increase of any stroke."

The authors concluded: "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, but with a reduction in periprocedural MI and cranial nerve injury. Strategies are urgently needed to identify patients who are best served by CAS vs CEA."

The pendulum seems to have swung toward carotid endarterectomy.


For the full abstract, click here.

Arch Neurol 68(2):172-184, February 2011 © 2011 to the American Medical Association
Carotid Artery Stenting vs Carotid Endarterectomy-Meta- analysis and Diversity-Adjusted Trial Sequential Analysis of Randomized Trials. Sripal Bangalore, Sunil Kumar, Jørn Wetterslev, et al. Correspondence to Dr. Bhatt: [email protected]

Category: K. Circulatory, N. Neurological. Keywords: carotid stenosis, stenting, endarterectomy, death, MI, stroke, cranial nerve injury, meta-analysis of randomized controlled trials, journal watch.
Synopsis edited by Dr Linda French, Toledo, Ohio. Posted on Global Family Doctor 1 March 2011

Pearls are an independent product of the Cochrane primary care group and are meant for educational use and not to guide clinical care.

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