Stenting versus surgery in patients with carotid stenosis after previous cervical radiation therapy: systematic review and meta-analysis.
OBJECTIVE
Patients with both carotid stenosis and previously cervical radiation therapy are considered "high risk" for carotid endarterectomy (CEA). Carotid angioplasty and stenting (CAS) seems a reasonable alternative, but neither the operative risk for CEA nor the effectiveness of CAS has been proven. The purpose of this study was to evaluate perioperative and long-term outcome of both procedures in patients with radiation therapy.


METHODS
A systematic search strategy with the synonyms "carotid artery stenosis" and "cervical irradiation" was conducted in MEDLINE and EMBASE databases. To provide and compare estimates of outcomes, pooled and metaregression analyses were performed.


RESULTS
Twenty-seven articles comprising 533 patients undergoing radiation therapy (361 CAS and 172 CEA) fulfilled our inclusion criteria. Pooled analysis showed perioperative risk for "any cerebrovascular adverse event" (CVE) of 3.9% (95% CI, 2.3%-6.7%) in CAS studies against 3.5% (95% CI, 1.5%-8.0%) in CEA studies (P=0.77). Risk for cranial nerve injury (CNI) after CEA was 9.2% (95% CI, 3.7%-21.1%) versus none after CAS. Late outcome showed rates of CVE favoring CEA (P=0.014). The rate of restenosis >50% was significantly higher in patients treated with CAS compared with CEA (P<0.003).


CONCLUSIONS
Both CAS and CEA proved to be feasible revascularization techniques with low risk for CVE. Although patients undergoing CEA had more temporary CNI, higher rates of late CVE and restenosis were identified after CAS.
UMC Utrecht, Department of Vascular Surgery, G04.129, PO Box 85500, 3508 GA Utrecht, The Netherlands.
Margriet
M
Fokkema
Anne G
AG
den Hartog
Michiel L
ML
Bots
Ingeborg
I
van der Tweel
Frans L
FL
Moll
Gert Jan
GJ
de Borst
D017130:Angioplasty; D016893:Carotid Stenosis / Q000401:mortality / Q000601:surgery* / Q000628:therapy*; D002574:Cervical Vertebrae; D003625:Data Collection; D016206:Databases, Bibliographic; D016894:Endarterectomy, Carotid; D057510:Endovascular Procedures; D006083:Graft Occlusion, Vascular; D006258:Head and Neck Neoplasms / Q000150:complications* / Q000532:radiotherapy*; D006801:Humans; D002546:Ischemic Attack, Transient / Q000150:complications; D016239:MEDLINE; D011878:Radiotherapy / Q000009:adverse effects*; D012044:Regression Analysis; D012307:Risk Factors; D015607:Stents; D020521:Stroke / Q000150:complications; D016896:Treatment Outcome