Randomized Controlled Trials Comparing Endarterectomy and Endovascular Treatment for Carotid Artery Stenosis

Background and Purpose—Endovascular treatment of carotid stenosis may be an alternative to surgical endarterectomy. We conducted a systematic review of the randomized evidence to assess the benefits and risks of endovascular treatment compared to surgery. Methods—Cochrane registers and online databases were searched and researchers in the field contacted. Outcome events were compared using odds ratios (ORs) calculated using the Peto fixed effect and Mantel-Haenszel random effects models if there was significant heterogeneity. Results—Ten trials involving 3178 patients were included. Not all contributed to each analysis. The primary outcome comparison of any stroke or death within 30 days of treatment favored surgery (fixed-effects OR 1.35), the difference was not statistically significant using the random effects model. Endovascular treatment was significantly better than surgery in avoiding cranial neuropathy (OR 0.15) and myocardial infarction (OR 0.34). There was no significant difference between endovascular treatment and surgery in the following comparisons: 30-day stroke, MI, or death (OR 1.12); 30-day disabling stroke or death (OR 1.19); 30-day death (OR 0.99); 24-month death or stroke (OR 1.26); and 30-day death or stroke in endovascular patients treated with or without protection devices (OR 0.75). Conclusions—The data are difficult to interpret because the trials are heterogeneous. Five trials were stopped early, perhaps leading to an overestimate of the risks of endovascular treatment. The results do not support a change in clinical practice away from recommending carotid endarterectomy as the treatment of choice for suitable carotid artery stenosis but support continued recruitment in the large ongoing trials. (Stroke. 2009;40:1373-1380.)