Overview of Primary and Secondary Analyses From 20 Randomised Controlled Trials Comparing Carotid Artery Stenting With Carotid Endarterectomy

<p>Objectives</p> <p>Overview of primary and secondary outcomes from 20 randomised controlled trials (RCTs) comparing carotid endarterectomy (CEA) with carotid artery stenting (CAS).</p> <p>Methods</p> <p>Systematic review and meta-analysis of data from 20 RCTs (126 publications).</p> <p>Results</p> <p>Peri-operative death/stroke was significantly higher after CAS. Excluding procedural risks, ipsilateral stroke was about 4% at 9-years for CEA/CAS, ie CAS was durable. To improve 10-year survival; peri-operative stroke/myocardial infarction must be prevented, mandating greater emphasis on risk factor control and best medical therapy (BMT). Reducing procedural death/stroke after CAS may be achieved through emerging CAS technologies, but better case selection is essential; eg perhaps preferentially performing CEA in; (i) symptomatic patients aged >70yrs; (ii) interventions <14 days of symptom onset and (iii) situations where stroke risk after CAS is higher (segmental/remote plaques, plaque length >13mm, heavy burden of white matter lesions (WML), avoiding situations where 2 or more stents need to be deployed). New WMLs are significantly more common after CAS and may be associated with higher rates of late stroke/TIA, requiring better risk factor control and BMT in patients with new, post-operative WMLs. There is no evidence that new WMLs predispose to cognitive impairment. Restenoses are more common after CAS, but do not increase late ipsilateral stroke. CEA is associated with a small, but significant increase in stroke ipsilateral to 70-99% restenoses, but procedural risks need to be <2% for redo CEA/CAS to be beneficial. </p> <p>Conclusions</p> <p>Questions to be answered include; (i) can CAS be undertaken <14 days of symptom-onset with outcomes similar to CEA; (ii) will emerging stent technologies and improved cerebral protection</p> <p>prevent stroke after CAS; (iii) what is the optimal volume of CAS procedures to maintain competency; (iv) how to deliver better risk factor control and BMT, and (v) is there a role for CEA/CAS in preventing/reversing cognitive impairment?</p> <p>What this paper adds to the literature?</p> <p>This is the first paper to provide a comprehensive overview of primary and secondary outcome data from 20 RCTs comparing CEA with CAS. It includes separate meta-analyses for peri-operative risks and late ipsilateral stroke. Secondary analyses include risk factors for stroke after CEA/CAS and its prevention; the effect of peri-operative stroke or myocardial infarction on long-term</p> <p>survival; non-stroke complications after CEA/CAS (cranial nerve injury, haematoma, arrhythmias and hypertension/hypotension); the significance of new white matter lesions on late stroke and</p> <p>cognitive impairment and whether asymptomatic 70-99% restenoses increase the risk of ipsilateral</p> <p>stroke after CEA and CAS.</p>