title: A systematic review and meta-analysis of randomized trials of carotid endarterectomy vs stenting.
abstract: OBJECTIVE
  The purpose of this systematic review and meta-analysis was to synthesize the available evidence derived from randomized controlled trials (RCTs) regarding the relative efficacy and safety of endarterectomy vs stenting in patients with carotid artery disease.
  
  
  METHODS
  We searched MEDLINE, EMBASE, Current Contents, and Cochrane CENTRAL through July 2010 to update previous systematic reviews. Two reviewers determined trial eligibility and extracted descriptive, methodologic, and outcome data (death, nonfatal stroke, and nonfatal myocardial infarction). Random-effects meta-analysis was used to pool relative risks and the I(2) statistic was used to assess heterogeneity.
  
  
  RESULTS
  Thirteen RCTs proved eligible enrolling 7484 patients, of which 80% had symptomatic disease. Methodological quality was moderate to high, with better quality among RCTs published after 2008. Compared with carotid endarterectomy, stenting was associated with increased risk of any stroke (relative risk [RR], 1.45; 95% confidence interval [CI], 1.06-1.99; I(2) = 40%), decreased risk of periprocedural myocardial infarction (MI; RR, 0.43; 95% CI, 0.26- 0.71; I(2) = 0%), and nonsignificant increase in mortality (RR, 1.40; 95% CI, 0.85-2.33; I(2) = 5%). When analysis was restricted to the two most recent trials with the better methodology and more contemporary technique, we found stenting to be associated with a significant increase in the risk of any stroke (RR, 1.82; 95% CI, 1.35-2.45) and mortality (RR, 2.53; 95% CI, 1.27-5.08) and a nonsignificant reduction of the risk of MI (RR, 0.39; 95% CI, 0.12-1.23). For every 1000 patients opting for stenting rather than endarterectomy, 19 more patients would have strokes and 10 fewer would have MIs. Outcome data in asymptomatic patients were sparse and imprecise; hence, these conclusions apply primarily to symptomatic patients.
  
  
  CONCLUSIONS
  Compared with endarterectomy, carotid artery stenting (CAS) significantly increases the risk of any stroke and decreases the risk of MI.
authors.affiliation: Knowledge and Encounter Research Unit, Mayo Clinic, Rochester, Minn 55905, USA. murad.mohammad@mayo.edu
authors.forename: Mohammad Hassan
authors.initials: MH
authors.lastname: Murad
authors.forename: Anas
authors.initials: A
authors.lastname: Shahrour
authors.forename: Nilay D
authors.initials: ND
authors.lastname: Shah
authors.forename: Victor M
authors.initials: VM
authors.lastname: Montori
authors.forename: John J
authors.initials: JJ
authors.lastname: Ricotta
mesh_terms: D017130:Angioplasty / Q000009:adverse effects / Q000295:instrumentation* / Q000401:mortality; D002340:Carotid Artery Diseases / Q000150:complications / Q000401:mortality / Q000601:surgery / Q000628:therapy*; D016894:Endarterectomy, Carotid / Q000009:adverse effects / Q000401:mortality; D019317:Evidence-Based Medicine; D006801:Humans; D009203:Myocardial Infarction / Q000209:etiology; D018579:Patient Selection; D016032:Randomized Controlled Trials as Topic; D018570:Risk Assessment; D012307:Risk Factors; D015607:Stents; D020521:Stroke / Q000209:etiology; D016896:Treatment Outcome