European Heart Journal Advance Access originally published online on October 27, 2009
European Heart Journal 2009 30(22):2693-2704; doi:10.1093/eurheartj/ehp471
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Carotid artery stenting vs. endarterectomy
1 Interventional Cardiology Unit, Division of Cardiology, University Hospital, Rue Micheli-du-Crest 24, 1211 Geneva, Switzerland
2 Division of Cardiovascular Medicine, Gill Heart Institute, University of Kentucky, Lexington, KY, USA
3 Department of Vascular Surgery, Heart and Vascular Institute, The Cleveland Clinic Foundation, Cleveland, OH, USA
Received 14 July 2009; revised 11 August 2009; accepted 8 October 2009; online publish-ahead-of-print 27 October 2009.
* Corresponding author. Tel: +41 22 37 27 208, Fax: +41 44 22 37 27 229, Email: marco.roffi{at}hcuge.ch
Randomized clinical trials have demonstrated that carotid endarterectomy (CEA) is superior to medical management for stroke prevention in patients with symptomatic and, to a lesser degree, asymptomatic internal carotid artery stenosis. However, large-scale registries have shown that the adverse event rates following CEA are commonly higher than observed in the trials. In the last decade, carotid artery stenting (CAS) has emerged as a less invasive alternative to surgery. In order to address the efficacy of CAS, we performed a meta-analysis of 10 randomized trials comparing CAS with CEA in 4648 mainly symptomatic patients. The analysis showed that CAS was associated with a statistically significant increased death or stroke rate at 30 days compared with CEA (odds ratio 1.60, 95% confidence interval 1.26–2.02). However, most of the trials had inadequate requirements in terms of endovascular expertise and did not mandate the use of emboli protection devices. Beyond 30 days, long-term follow-up of the trials previously reported suggest that both revascularization techniques are equivalent in terms of stroke prevention. Conversely, large-scale high-quality CAS registries—mostly with independent neurological assessment and clinical event committee adjudication—have reported results in the range of current recommendation for CEA in over 20 000 patients, despite the fact that the majority of patients were at high risk for surgery. Until further data become available, the performance of CAS should be limited to protocols or centres of excellence and targeted especially to patients at high risk for surgery.
Key Words: Carotid artery stenting • Carotid endarterectomy • Meta-analysis • Carotid artery stenosis • Randomized trials • Emboli protection