title: Carotid revascularization: a systematic review of the evidence.
abstract: OBJECTIVE
  The aim of this study is to provide an evidence-based review of the periprocedural safety and long-term effectiveness of carotid artery stenting (CAS) compared to carotid endarterectomy (CEA), with particular attention paid to the use of embolic protection devices and patients at high risk for CEA.
  
  
  METHODS
  Electronic databases (Ovid Medline, Cochrane central register of controlled trials, Pubmed, and Embase) were searched to identify: (1) randomized controlled trials (RCT) comparing outcomes of CEA and CAS, and (2) prospective clinical trials assessing the safety of CAS in patients at high surgical risk. Pooled incidence rates and one-sided 95% confidence interval for the periprocedural and long-term composite end-point of stroke, myocardial infarction, or death among high surgical risk patients were generated and compared to objective performance criteria (OPC) reported by previous trials.
  
  
  RESULTS
  Six RCTs and 14 prospective clinical trials met our search criteria. Selected RCTs showed inconsistency in reported periprocedural and long-term outcome rates. Pooled incidence rates of the periprocedural and long-term composite end-point of stroke, myocardial infarction or death in high surgical risk candidates were 5.59% and 7.92%, respectively. These results were noninferior to selected OPCs (P-value <0.001).
  
  
  CONCLUSIONS
  CAS represents a safe and effective stroke prevention strategy in high surgical risk patients when compared with CEA. The inconsistent results from the RCTs and the improved outcomes in the prospective clinical trials are likely related to variability in operator experience, use of embolic protection devices, and patient selection strategies.
authors.affiliation: Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA. mohdamluji@yahoo.com
authors.forename: Mohammed Salim
authors.initials: MS
authors.lastname: Al-Damluji
authors.forename: Sameer
authors.initials: S
authors.lastname: Nagpal
authors.forename: Erik
authors.initials: E
authors.lastname: Stilp
authors.forename: Michael
authors.initials: M
authors.lastname: Remetz
authors.forename: Carlos
authors.initials: C
authors.lastname: Mena
mesh_terms: D000367:Age Factors; D016893:Carotid Stenosis / Q000628:therapy*; D057505:Embolic Protection Devices; D016894:Endarterectomy, Carotid; D006801:Humans; D009203:Myocardial Infarction / Q000453:epidemiology; D011788:Quality of Life; D016032:Randomized Controlled Trials as Topic; D018570:Risk Assessment; D015607:Stents; D020521:Stroke / Q000453:epidemiology / Q000517:prevention & control*; D016896:Treatment Outcome