Endarterectomy vs stenting for carotid artery stenosis: a systematic review and meta-analysis.
OBJECTIVE
The relative efficacy and safety of endarterectomy and stenting in patients with carotid stenosis remain unclear. In this review we synthesize the available evidence derived from randomized controlled trials (RCTs) that compared the two procedures in terms of the risks of death, stroke (disabling and nondisabling), and nonfatal myocardial infarction.


METHODS
We searched for RCTs in MEDLINE, EMBASE, Current Contents, and Cochrane CENTRAL; expert files, and bibliographies of included articles. Two reviewers, working independently, determined trial eligibility and extracted descriptive, methodologic, and outcome data from each eligible RCT. Random-effects meta-analysis was used to assess relative and absolute risks and the I(2) statistic was used to assess heterogeneity of treatment effect among trials.


RESULTS
Ten RCTs with 3182 participants proved eligible. At 30 days and compared with endarterectomy, carotid stenting was associated with a nonsignificant reduction in the risk of death (relative risk [RR], 0.61; 95% confidence interval [CI], 0.27-1.37; I(2) = 0%), a nonsignificant reduction in the risk of nonfatal myocardial infarction (RR, 0.43; 95% CI 0.17-1.11; I(2) = 0%), and a nonsignificant increase in the risk of any stroke (RR, 1.29; 95% CI, 0.73-2.26; I(2) = 40%) and major/disabling stroke (RR, 1.06; 95% CI, 0.32-3.52; I(2) = 45%). If one considers the two procedures equivalent if the absolute difference in events is <2%, these results provide moderate-quality evidence for equivalence with respect to death (risk difference [RD] -0.40, 95% CI -1.02 to 0.40) and nonfatal myocardial infarction (RD, -0.70; 95% CI -1.90 to 0.50), but because of much wider CI, only low-quality evidence of equivalence in stroke (RD, 1.00; 95% CI, -1.00 to 3.10).


CONCLUSIONS
In RCTs, carotid stenting and carotid endarterectomy seem equivalent in terms of death and nonfatal myocardial infarction. Although the impact on stroke remains unestablished, results are consistent with a clinically important increase in stroke risk with stenting, an intervention that aims at reducing the risk of stroke.
Murad
M Hassan
MH
Divisions of Preventive, Occupational and Aerospace Medicine, Mayo Clinic, Rochester, Minn, USA. Murad.Mohammad@mayo.edu
Flynn
David N
DN
Elamin
Mohamed B
MB
Guyatt
Gordon H
GH
Hobson
Robert W
RW
Erwin
Patricia J
PJ
Montori
Victor M
VM
D000800:Angioplasty, Balloon / Q000009:adverse effects / Q000379:methods*; D001027:Aortography / Q000379:methods; D016893:Carotid Stenosis / Q000175:diagnosis* / Q000401:mortality* / Q000628:therapy*; D002423:Cause of Death; D016894:Endarterectomy, Carotid / Q000009:adverse effects / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D018579:Patient Selection; D016032:Randomized Controlled Trials as Topic; D018570:Risk Assessment; D012720:Severity of Illness Index; D015607:Stents; D016019:Survival Analysis; D016896:Treatment Outcome; D018616:Ultrasonography, Doppler, Duplex