Long-term outcomes of carotid artery stenting <i>versus</i> carotid endarterectomy in the treatment of carotid artery stenosis: a meta-analysis of randomized controlled trials_West China Medical Journal

Authors：

 CHENG Liping , LIAO Ziwei , HUO Ruimin , ZHANG Miaomiao , LI Xiaoxue

Second Neurology Department, Handan First Hospital, Handan, Hebei 056002, P. R. China;

Corresponding?author：

CHENG Liping, Email: clp717@126.com

Keywords：

Carotid artery stenosis; Stents; Endometectomy; Randomized controlled trial; Meta-analysis

DOI：

10.7507/1002-0179.201911029

Video：

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Objective To compare the long-term efficacy of carotid artery stenting (CAS) and carotid endarterectomy (CEA) in the treatment of carotid artery stenosis by meta-analysis. Methods PubMed, Embase, Medline, Cochrane Library, China National Knowledge Infrastructure, Wanfang database, Chongqing VIP database, and SinoMed were searched, for randomized controlled trials comparing the efficacy of CAS and CEA in the treatment of carotid artery stenosis published before September 2nd, 2021. Stata 15.1 software was used to analyze the long-term outcome data, including any stroke, ipsilateral stroke, fatal or disabling stroke, any death, combined endpoint of stroke or death, and carotid artery restenosis. Results A total of 20 English articles from 9 studies were included, involving 8551 patients (4658 in the CAS group and 3893 in the CEA group). The medians of the follow-up time of these studies were 2-10 years. The meta-analysis showed that the risks of any stroke [hazard ratio (HR)=1.33, 95% confidence interval (CI) (1.16, 1.52), P<0.0001], ipsilateral stroke [HR=1.26, 95%CI (1.02, 1.55), P=0.034], and the combined endpoint of stroke or death [HR=1.17, 95%CI (1.02, 1.33), P=0.021] in the CAS group were significantly higher than those in the CEA group, while the risks of fatal or disabling stroke [HR=1.19, 95%CI (0.94, 1.51), P=0.152], any death [HR=1.06, 95%CI (0.95, 1.18), P=0.302], and restenosis [HR=1.20, 95%CI (0.96, 1.49), P=0.111] were not significantly different between the CAS group and the CEA group. Conclusions CAS and CEA have similar risks in terms of long-term fatal or disabling stroke, death, and carotid artery restenosis, but the long-term risks of any stroke, ipsilateral stroke and combined endpoint of death or stroke of CAS are higher than those of CEA. CEA is still the preferred non-drug method for carotid artery stenosis.

Citation： CHENG Liping, LIAO Ziwei, HUO Ruimin, ZHANG Miaomiao, LI Xiaoxue. Long-term outcomes of carotid artery stenting versus carotid endarterectomy in the treatment of carotid artery stenosis: a meta-analysis of randomized controlled trials. West China Medical Journal, 2021, 36(10): 1405-1413. doi: 10.7507/1002-0179.201911029 Copy

1.	Petty GW, Brown RD, Whisnant JP, et al. Ischemic stroke subtypes: a population-based study of incidence and risk factors. Stroke, 1999, 30(12): 2513-2516.
2.	Noiphithak R, Liengudom A. Recent update on carotid endarterectomy versus carotid artery stenting. Cerebrovasc Dis, 2017, 43(1/2): 68-75.
3.	中華醫學會外科學分會血管外科學組. 頸動脈狹窄診治指南. 中華血管外科雜志, 2017, 2(2): 78-84.
4.	European Carotid Surgery Trialists Collaborative Group. Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST). Lancet, 1998, 351(9113): 1379-1387.
5.	Walker MD, Marler JR, Goldstein M, et al. Endarterectomy for asymptomatic carotid artery stenosis. JAMA, 1995(273): 1421-1428.
6.	Meier P, Knapp G, Tamhane U, et al. Short term and intermediate term comparison of endarterectomy versus stenting for carotid artery stenosis: systematic review and meta-analysis of randomised controlled clinical trials. BMJ, 2010, 340: c467.
7.	Liu ZJ, Fu WG, Guo ZY, et al. Updated systematic review and meta-analysis of randomized clinical trials comparing carotid artery stenting and carotid endarterectomy in the treatment of carotid stenosis. Ann Vasc Surg, 2012, 26(4): 576-590.
8.	Bonati LH, Fraedrich G. Age modifies the relative risk of stenting versus endarterectomy for symptomatic carotid stenosis: a pooled analysis of EVA-3S, SPACE and ICSS. Eur J Vasc Endovasc Surg, 2011, 41(2): 153-158.
9.	Bonati L, Lyrer P, Ederle J, et al. Percutaneous transluminal balloon angioplasty and stenting for carotid artery stenosis. Cochrane Database Syst Rev, 2012, 9(9): CD000515.
10.	曾憲濤, 冷衛東, 李勝, 等. 如何正確理解及使用GRADE系統. 中國循證醫學雜志, 2011, 11(9): 985-990.
11.	Tierney JF, Stewart LA, Ghersi D, et al. Practical methods for incorporating summary time-to-event data into meta-analysis. Trials, 2007, 8: 16.
12.	Mannheim D, Karmeli R. A prospective randomized trial comparing endarterectomy to stenting in severe asymptomatic carotid stenosis. J Cardiovasc Surg (Torino), 2017, 58(6): 814-817.
13.	Brooks WH, McClure RR, Jones MR, et al. Carotid angioplasty and stenting versus carotid endarterectomy for treatment of asymptomatic carotid stenosis: a randomized trial in a community hospital. Neurosurgery, 2004, 54(2): 318-324.
14.	Brooks WH, McClure RR, et al. Carotid angioplasty and stenting versus carotid endarterectomy: randomized trial in a community hospital. J Am Coll Cardiol, 2001, 38(6): 1589-1595.
15.	Brooks William H, Jones Michael R, Gisler Paula, et al. Carotid angioplasty with stenting versus endarterectomy: 10-year randomized trial in a community hospital. JACC Cardiovasc Interv, 2014, 7(2): 163-168.
16.	Rosenfield K, Matsumura JS, Chaturvedi S, et al. Randomized trial of stent versus surgery for asymptomatic carotid stenosis. N Engl J Med, 2016, 374(11): 1011-1020.
17.	Investigators C. Endovascular versus surgical treatment in patients with carotid stenosis in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS): a randomised trial. Lancet, 2001, 357(9270): 1729-1737.
18.	Ederle J, Bonati LH, Dobson J, et al. Endovascular treatment with angioplasty or stenting versus endarterectomy in patients with carotid artery stenosis in the Carotid And Vertebral Artery Transluminal Angioplasty Study (CAVATAS): long-term follow-up of a randomised trial. Lancet Neurol, 2009, 8(10): 898-907.
19.	Brott TG, Howard G, Roubin GS, et al. Long-term results of stenting versus endarterectomy for carotid-artery stenosis. N Engl J Med, 2016, 374(11): 535-536.
20.	Brott TG, Hobson RW, Howard G. Stenting versus endarterectomy for treatment of carotid-artery stenosis. J Vasc Surg, 2010, 363(1): 11-23.
21.	Voeks JH, Howard G, Roubin GS. Age and outcomes after carotid stenting and endarterectomy: the carotid revascularization endarterectomy versus stenting trial. J Vasc Surg, 2012, 42(12): 3484-3490.
22.	Virginia JH, Helmi LL, Ariane M. Influence of sex on outcomes of stenting versus endarterectomy: a subgroup analysis of the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST). Lancet Neurol, 2011, 10(6): 530-537.
23.	EVA-3S Investigators. Endarterectomy vs. angioplasty in patients with symptomatic severe carotid stenosis (EVA-3S) trial. Cerebrovasc Dis, 2004, 18(1): 62-65.
24.	Mas JL, Trinquart L, Leys D, et al. Endarterectomy versus angioplasty in patients with symptomatic severe carotid stenosis (EVA-3S) trial: results up to 4 years from a randomised, multicentre trial. Lancet Neurol, 2008, 7(10): 885-892.
25.	Mas JL, Arquizan C, Calvet D. Long-term follow-up study of endarterectomy versus angioplasty in patients with symptomatic severe carotid stenosis trial. J Vasc Surg, 2015, 61(2): 568-569.
26.	Ederle J, Dobson J, Featherstone RL, et al. Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): an interim analysis of a randomised controlled trial. Lancet, 2010, 375(9719): 985-997.
27.	Featherstone RL, Dobson J, Ederle J, et al. Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): a randomised controlled trial with cost-effectiveness analysis. Health Technol Assess, 2016, 20(20): 1-94.
28.	Yadav JS, Wholey MH, Kuntz RE. Protected carotid-artery stenting versus endarterectomy in high-risk patients. N Engl J Med, 2004, 351(15): 1493-1501.
29.	Gurm HS, Yadav JS, Fayad P, et al. Long-term results of carotid stenting versus endarterectomy in high-risk patients. N Engl J Med, 2008, 358(15): 1572-1579.
30.	Group SC, Ringleb PA, Allenberg J, et al. 30 day results from the SPACE trial of stent-protected angioplasty versus carotid endarterectomy in symptomatic patients: a randomised non-inferiority trial. Lancet, 2006, 368(7): 1239-1247.
31.	Eckstein HH, Ringleb P, Allenberg JR, et al. Results of the stent-protected angioplasty versus carotid endarterectomy (SPACE) study to treat symptomatic stenoses at 2 years: a multinational, prospective, randomised trial. Lancet Neurol, 2008, 7(10): 893-902.
32.	Vincent S, Eberg M, Eisenberg MJ, et al. Meta-analysis of randomized controlled trials comparing the long-term outcomes of carotid artery stenting versus endarterectomy. Circ Cardiovasc Qual Outcomes, 2015, 8(6 Suppl 3): S99-S108.
33.	張鵬飛, 郭艷婷, 趙文可, 等. 頸動脈支架置入術與內膜切除術治療頸動脈狹窄的遠期轉歸比較: 隨機對照試驗的匯總分析. 國際腦血管病雜志, 2017, 25(4): 310-319.
34.	Zhang L, Zhao Z, Ouyang Y, et al. Systematic review and meta-analysis of carotid artery stenting versus endarterectomy for carotid stenosis: a chronological and worldwide study. Medicine, 2015, 94(26): e1060.

1. Petty GW, Brown RD, Whisnant JP, et al. Ischemic stroke subtypes: a population-based study of incidence and risk factors. Stroke, 1999, 30(12): 2513-2516.
2. Noiphithak R, Liengudom A. Recent update on carotid endarterectomy versus carotid artery stenting. Cerebrovasc Dis, 2017, 43(1/2): 68-75.
3. 中華醫學會外科學分會血管外科學組. 頸動脈狹窄診治指南. 中華血管外科雜志, 2017, 2(2): 78-84.
4. European Carotid Surgery Trialists Collaborative Group. Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST). Lancet, 1998, 351(9113): 1379-1387.
5. Walker MD, Marler JR, Goldstein M, et al. Endarterectomy for asymptomatic carotid artery stenosis. JAMA, 1995(273): 1421-1428.
6. Meier P, Knapp G, Tamhane U, et al. Short term and intermediate term comparison of endarterectomy versus stenting for carotid artery stenosis: systematic review and meta-analysis of randomised controlled clinical trials. BMJ, 2010, 340: c467.
7. Liu ZJ, Fu WG, Guo ZY, et al. Updated systematic review and meta-analysis of randomized clinical trials comparing carotid artery stenting and carotid endarterectomy in the treatment of carotid stenosis. Ann Vasc Surg, 2012, 26(4): 576-590.
8. Bonati LH, Fraedrich G. Age modifies the relative risk of stenting versus endarterectomy for symptomatic carotid stenosis: a pooled analysis of EVA-3S, SPACE and ICSS. Eur J Vasc Endovasc Surg, 2011, 41(2): 153-158.
9. Bonati L, Lyrer P, Ederle J, et al. Percutaneous transluminal balloon angioplasty and stenting for carotid artery stenosis. Cochrane Database Syst Rev, 2012, 9(9): CD000515.
10. 曾憲濤, 冷衛東, 李勝, 等. 如何正確理解及使用GRADE系統. 中國循證醫學雜志, 2011, 11(9): 985-990.
11. Tierney JF, Stewart LA, Ghersi D, et al. Practical methods for incorporating summary time-to-event data into meta-analysis. Trials, 2007, 8: 16.
12. Mannheim D, Karmeli R. A prospective randomized trial comparing endarterectomy to stenting in severe asymptomatic carotid stenosis. J Cardiovasc Surg (Torino), 2017, 58(6): 814-817.
13. Brooks WH, McClure RR, Jones MR, et al. Carotid angioplasty and stenting versus carotid endarterectomy for treatment of asymptomatic carotid stenosis: a randomized trial in a community hospital. Neurosurgery, 2004, 54(2): 318-324.
14. Brooks WH, McClure RR, et al. Carotid angioplasty and stenting versus carotid endarterectomy: randomized trial in a community hospital. J Am Coll Cardiol, 2001, 38(6): 1589-1595.
15. Brooks William H, Jones Michael R, Gisler Paula, et al. Carotid angioplasty with stenting versus endarterectomy: 10-year randomized trial in a community hospital. JACC Cardiovasc Interv, 2014, 7(2): 163-168.
16. Rosenfield K, Matsumura JS, Chaturvedi S, et al. Randomized trial of stent versus surgery for asymptomatic carotid stenosis. N Engl J Med, 2016, 374(11): 1011-1020.
17. Investigators C. Endovascular versus surgical treatment in patients with carotid stenosis in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS): a randomised trial. Lancet, 2001, 357(9270): 1729-1737.
18. Ederle J, Bonati LH, Dobson J, et al. Endovascular treatment with angioplasty or stenting versus endarterectomy in patients with carotid artery stenosis in the Carotid And Vertebral Artery Transluminal Angioplasty Study (CAVATAS): long-term follow-up of a randomised trial. Lancet Neurol, 2009, 8(10): 898-907.
19. Brott TG, Howard G, Roubin GS, et al. Long-term results of stenting versus endarterectomy for carotid-artery stenosis. N Engl J Med, 2016, 374(11): 535-536.
20. Brott TG, Hobson RW, Howard G. Stenting versus endarterectomy for treatment of carotid-artery stenosis. J Vasc Surg, 2010, 363(1): 11-23.
21. Voeks JH, Howard G, Roubin GS. Age and outcomes after carotid stenting and endarterectomy: the carotid revascularization endarterectomy versus stenting trial. J Vasc Surg, 2012, 42(12): 3484-3490.
22. Virginia JH, Helmi LL, Ariane M. Influence of sex on outcomes of stenting versus endarterectomy: a subgroup analysis of the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST). Lancet Neurol, 2011, 10(6): 530-537.
23. EVA-3S Investigators. Endarterectomy vs. angioplasty in patients with symptomatic severe carotid stenosis (EVA-3S) trial. Cerebrovasc Dis, 2004, 18(1): 62-65.
24. Mas JL, Trinquart L, Leys D, et al. Endarterectomy versus angioplasty in patients with symptomatic severe carotid stenosis (EVA-3S) trial: results up to 4 years from a randomised, multicentre trial. Lancet Neurol, 2008, 7(10): 885-892.
25. Mas JL, Arquizan C, Calvet D. Long-term follow-up study of endarterectomy versus angioplasty in patients with symptomatic severe carotid stenosis trial. J Vasc Surg, 2015, 61(2): 568-569.
26. Ederle J, Dobson J, Featherstone RL, et al. Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): an interim analysis of a randomised controlled trial. Lancet, 2010, 375(9719): 985-997.
27. Featherstone RL, Dobson J, Ederle J, et al. Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): a randomised controlled trial with cost-effectiveness analysis. Health Technol Assess, 2016, 20(20): 1-94.
28. Yadav JS, Wholey MH, Kuntz RE. Protected carotid-artery stenting versus endarterectomy in high-risk patients. N Engl J Med, 2004, 351(15): 1493-1501.
29. Gurm HS, Yadav JS, Fayad P, et al. Long-term results of carotid stenting versus endarterectomy in high-risk patients. N Engl J Med, 2008, 358(15): 1572-1579.
30. Group SC, Ringleb PA, Allenberg J, et al. 30 day results from the SPACE trial of stent-protected angioplasty versus carotid endarterectomy in symptomatic patients: a randomised non-inferiority trial. Lancet, 2006, 368(7): 1239-1247.
31. Eckstein HH, Ringleb P, Allenberg JR, et al. Results of the stent-protected angioplasty versus carotid endarterectomy (SPACE) study to treat symptomatic stenoses at 2 years: a multinational, prospective, randomised trial. Lancet Neurol, 2008, 7(10): 893-902.
32. Vincent S, Eberg M, Eisenberg MJ, et al. Meta-analysis of randomized controlled trials comparing the long-term outcomes of carotid artery stenting versus endarterectomy. Circ Cardiovasc Qual Outcomes, 2015, 8(6 Suppl 3): S99-S108.
33. 張鵬飛, 郭艷婷, 趙文可, 等. 頸動脈支架置入術與內膜切除術治療頸動脈狹窄的遠期轉歸比較: 隨機對照試驗的匯總分析. 國際腦血管病雜志, 2017, 25(4): 310-319.
34. Zhang L, Zhao Z, Ouyang Y, et al. Systematic review and meta-analysis of carotid artery stenting versus endarterectomy for carotid stenosis: a chronological and worldwide study. Medicine, 2015, 94(26): e1060.

West China Medical Journal

Long-term outcomes of carotid artery stenting versus carotid endarterectomy in the treatment of carotid artery stenosis: a meta-analysis of randomized controlled trials

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