Endovascular stenting or carotid endarterectomy for treatment of carotid stenosis: a meta-analysis.

OBJECTIVE To compare carotid artery stenting with open carotid surgery for the treatment of symptomatic or asymptomatic carotid artery stenosis in terms of stroke, myocardial infarction, and death at 30 days. DESIGN A meta-analysis of parallel randomized clinical trials (RCTs) (blind or open) published (full article available) in English. SETTING University-based electronic search. INTERVENTIONS Patients were submitted to carotid artery stenting or open carotid artery surgery. MEASUREMENTS AND MAIN RESULTS Ten RCTs including 6,950 patients were found. There was a moderate amount of heterogeneity (I(2) = 49.8%) in stroke at 30 days when all available data were added together. Heterogeneity fell to 0% when only studies (n = 4) in which cerebral protection devices were used in a high percentage of the patients in the stenting groups were retained. Those 4 studies included 5,012 patients. Carotid endarterectomy reduced the risk ratio (RR) of stroke at 30 days compared with stenting (RR = 0.50; 95% confidence interval (CI), 0.38-0.67; p = 0.000002; event rate 2.8% and 5.6%). Carotid endarterectomy increases the risk of myocardial infarction (RR = 2.16 [95% CI, 1.32-3.54], p = 0.002, heterogeneity 0%, event rate 1.8% and 0.9%). There was no difference in death at 30 days (RR = 0.72 [0.42-1.24] (random effects model), p = 0.23, I(2) = 2.45%, p value for heterogeneity = 0.41; event rate 0.7% and 1.1% for carotid endarterectomy and stenting, respectively). CONCLUSIONS Compared with stenting, carotid endarterectomy decreases the risk of stroke at 30 days, increases the risk of myocardial infarction, and does not affect the risk of death.