Endarterectomy vs stenting for carotid artery stenosis: A systematic review and meta-analysis

Mohammad H Murad, David N. Flynn, Mohamed B. Elamin, Gordon H. Guyatt, Robert W. Hobson, Patricia J. Erwin, Victor Manuel Montori

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Abstract

Objectives: The relative efficacy and safety of endarterectomy and stenting in patients with carotid stenosis remain unclear. In this review we synthesize the available evidence derived from randomized controlled trials (RCTs) that compared the two procedures in terms of the risks of death, stroke (disabling and nondisabling), and nonfatal myocardial infarction. Methods: We searched for RCTs in MEDLINE, EMBASE, Current Contents, and Cochrane CENTRAL; expert files, and bibliographies of included articles. Two reviewers, working independently, determined trial eligibility and extracted descriptive, methodologic, and outcome data from each eligible RCT. Random-effects meta-analysis was used to assess relative and absolute risks and the I2 statistic was used to assess heterogeneity of treatment effect among trials. Results: Ten RCTs with 3182 participants proved eligible. At 30 days and compared with endarterectomy, carotid stenting was associated with a nonsignificant reduction in the risk of death (relative risk [RR], 0.61; 95% confidence interval [CI], 0.27-1.37; I2 = 0%), a nonsignificant reduction in the risk of nonfatal myocardial infarction (RR, 0.43; 95% CI 0.17-1.11; I2 = 0%), and a nonsignificant increase in the risk of any stroke (RR, 1.29; 95% CI, 0.73-2.26; I2 = 40%) and major/disabling stroke (RR, 1.06; 95% CI, 0.32-3.52; I2 = 45%). If one considers the two procedures equivalent if the absolute difference in events is <2%, these results provide moderate-quality evidence for equivalence with respect to death (risk difference [RD] -0.40, 95% CI -1.02 to 0.40) and nonfatal myocardial infarction (RD, -0.70; 95% CI -1.90 to 0.50), but because of much wider CI, only low-quality evidence of equivalence in stroke (RD, 1.00; 95% CI, -1.00 to 3.10). Conclusion: In RCTs, carotid stenting and carotid endarterectomy seem equivalent in terms of death and nonfatal myocardial infarction. Although the impact on stroke remains unestablished, results are consistent with a clinically important increase in stroke risk with stenting, an intervention that aims at reducing the risk of stroke.

Original languageEnglish (US)
Pages (from-to)487-493
Number of pages7
JournalJournal of Vascular Surgery
Volume48
Issue number2
DOIs
StatePublished - Aug 2008

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Endarterectomy
Carotid Stenosis
Meta-Analysis
Confidence Intervals
Stroke
Randomized Controlled Trials
Myocardial Infarction
Carotid Endarterectomy
Risk Reduction Behavior
Bibliography
MEDLINE

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Surgery

Cite this

Endarterectomy vs stenting for carotid artery stenosis : A systematic review and meta-analysis. / Murad, Mohammad H; Flynn, David N.; Elamin, Mohamed B.; Guyatt, Gordon H.; Hobson, Robert W.; Erwin, Patricia J.; Montori, Victor Manuel.

In: Journal of Vascular Surgery, Vol. 48, No. 2, 08.2008, p. 487-493.

Research output: Contribution to journalArticle

Murad, Mohammad H ; Flynn, David N. ; Elamin, Mohamed B. ; Guyatt, Gordon H. ; Hobson, Robert W. ; Erwin, Patricia J. ; Montori, Victor Manuel. / Endarterectomy vs stenting for carotid artery stenosis : A systematic review and meta-analysis. In: Journal of Vascular Surgery. 2008 ; Vol. 48, No. 2. pp. 487-493.
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T2 - A systematic review and meta-analysis

AU - Murad, Mohammad H

AU - Flynn, David N.

AU - Elamin, Mohamed B.

AU - Guyatt, Gordon H.

AU - Hobson, Robert W.

AU - Erwin, Patricia J.

AU - Montori, Victor Manuel

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N2 - Objectives: The relative efficacy and safety of endarterectomy and stenting in patients with carotid stenosis remain unclear. In this review we synthesize the available evidence derived from randomized controlled trials (RCTs) that compared the two procedures in terms of the risks of death, stroke (disabling and nondisabling), and nonfatal myocardial infarction. Methods: We searched for RCTs in MEDLINE, EMBASE, Current Contents, and Cochrane CENTRAL; expert files, and bibliographies of included articles. Two reviewers, working independently, determined trial eligibility and extracted descriptive, methodologic, and outcome data from each eligible RCT. Random-effects meta-analysis was used to assess relative and absolute risks and the I2 statistic was used to assess heterogeneity of treatment effect among trials. Results: Ten RCTs with 3182 participants proved eligible. At 30 days and compared with endarterectomy, carotid stenting was associated with a nonsignificant reduction in the risk of death (relative risk [RR], 0.61; 95% confidence interval [CI], 0.27-1.37; I2 = 0%), a nonsignificant reduction in the risk of nonfatal myocardial infarction (RR, 0.43; 95% CI 0.17-1.11; I2 = 0%), and a nonsignificant increase in the risk of any stroke (RR, 1.29; 95% CI, 0.73-2.26; I2 = 40%) and major/disabling stroke (RR, 1.06; 95% CI, 0.32-3.52; I2 = 45%). If one considers the two procedures equivalent if the absolute difference in events is <2%, these results provide moderate-quality evidence for equivalence with respect to death (risk difference [RD] -0.40, 95% CI -1.02 to 0.40) and nonfatal myocardial infarction (RD, -0.70; 95% CI -1.90 to 0.50), but because of much wider CI, only low-quality evidence of equivalence in stroke (RD, 1.00; 95% CI, -1.00 to 3.10). Conclusion: In RCTs, carotid stenting and carotid endarterectomy seem equivalent in terms of death and nonfatal myocardial infarction. Although the impact on stroke remains unestablished, results are consistent with a clinically important increase in stroke risk with stenting, an intervention that aims at reducing the risk of stroke.

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