Short-Term Outcomes of Carotid Artery Stenting versus Carotid Endarterectomy in the Treatment of Carotid Stenosis: An Up-Dated Meta-Analysis of Randomized Controlled Trials

Year 2023, , 242 - 250, 30.12.2023

İzzet Aydemir , İhsan Doğan , Afsun Ezel Esatoğlu

https://doi.org/10.18678/dtfd.1306382

Abstract

Aim: Carotid artery stenting is thought to result in better outcomes when compared to carotid endarterectomy. To evaluate this hypothesis, a far-reaching of published randomized controlled trials were performed to evaluate the short-term outcomes of carotid artery stenting versus carotid endarterectomy for patients undergoing carotid artery stenosis.
Material and Methods: A comprehensive search of trials published from 1994 until December 31, 2022, was performed using Science Direct, PubMed, Web of Science, Sage, Ebscohost, Scopus, and Cochrane Central electronic databases. Major endpoints (any stroke, myocardial infarction, and all-cause mortality) were extracted from the publications. Pooled risk ratio (RR) and 95% confidence interval (CI) were calculated using a fixed-effects model.
Results: 21 trials involving 15518 patients (8514 with stenting, 7004 with endarterectomy) were included in the meta-analysis. Stenting was associated with a significantly increased risk of short-term any stroke (RR=1.555, 95% CI: 1.307-1.851, p<0.001) yet a significantly decreased risk of short-term myocardial infarction (RR=0.458, 95% CI: 0.319-0.660, p<0.001) when compared with endarterectomy. No significant difference was found in all-cause mortality between the two interventions (RR=1.277, 95% CI: 0.835-1.952, p=0.259), but with a trend toward superiority favoring endarterectomy.
Conclusion: Endarterectomy was found to be superior in terms of any stroke and partially regarding all-cause mortality, whereas stenting was found to be superior in terms of myocardial infarction. Yet for robust results, further studies are needed to address the relative effectiveness of stenting versus endarterectomy in the future.

Keywords

Carotid endarterectomy, meta-analysis, randomized controlled trial, short-terms outcomes, carotid artery stenting

Karotis Stenozu Tedavisinde Karotis Arter Stentleme ve Karotis Endarterektomi Yöntemlerinin Kısa Dönem Sonuçları: Randomize Kontrollü Çalışmaların Güncel Bir Meta-Analizi

Abstract

Amaç: Karotis arter stentlemenin karotis endarterektomiye kıyasla daha iyi sonuçlar ürettiği düşünülmektedir. Bu hipotezi sınamak için, karotis arter stenozu geçiren hastalarda karotis arter stentleme ve karotis endarterektominin kısa süreli sonuçlarını değerlendirmek üzere yayınlanmış randomize kontrollü çalışmaların geniş kapsamlı değerlendirmesi yapıldı.
Gereç ve Yöntemler: Science Direct, PubMed, Web of Science, Sage, Ebscohost, Scopus ve Cochrane Central elektronik veri tabanları kullanılarak 1994'ten 31 Aralık 2022'ye kadar yayınlanmış olan denemelerin kapsamlı bir araştırması yapıldı. Yayınlardan temel sonlanım noktaları (herhangi bir inme türü, miyokard enfarktüsü ve tüm nedenlere bağlı ölüm) çıkarıldı. Sabit etkiler modeli iler etki büyüklüğü risk oranı (RO) ve %95 güven aralığı (GA) hesaplandı.
Bulgular: Bu meta-analizine 15518 hastayı (8514 stentleme, 7004 endarterektomi) içeren 21 çalışma dahil edildi. Endarterektomi ile karşılaştırıldığında, stentleme, kısa süreli herhangi bir inme riskinde anlamlı derecede artma (RR=1,555; %95 GA: 1,307-1,851; p<0,001), ancak kısa süreli miyokard enfarktüsü riskinde ise azalma (RR=0,458; %95 GA: 0,319-0,660; p<0,001) ile ilişkiliydi. İki müdahale arasında tüm nedenlere bağlı ölüm açısından anlamlı bir fark yokken (RR=1,277; %95 GA: 0,835-1,952; p=0,259) endarterektomi lehine üstünlük eğilimi vardı.
Sonuç: Endarterektominin herhangi bir inme türü açısından ve kısmen de tüm nedenlere bağlı ölüm açısından üstün olduğu, stentlemenin ise miyokard enfarktüsü açısından üstün olduğu görüldü. Ancak daha sağlam sonuçlar için gelecekte stentlemenin endarterektomiye karşı göreceli etkinliğini ele alan daha fazla çalışmalara ihtiyaç vardır.

Keywords

Karotis endarterektomi, meta-analizi, randomize kontrollü çalışmalar, kısa-dönem sonuçlar, karotis arter stentleme

References

• Song P, Fang Z, Wang H, Cai Y, Rahimi K, Zhu Y, et al. Global and regional prevalence, burden, and risk factors for carotid atherosclerosis: a systematic review, meta-analysis, and modelling study. Lancet. 2020;8(5):e721-9.
• Mantese VA, Timaran CH, Chiu D, Begg RJ, Brott TG; CREST Investigators. The carotid revascularization endarterectomy versus stenting trial (CREST): stenting versus carotid endarterectomy for carotid disease. Stroke. 2010;41(10 Suppl):S31-4.
• Morris DR, Ayabe K, Inoue T, Sakai N, Bulbulia R, Halliday A, et al. Evidence-based carotid interventions for stroke prevention: state-of-the-art review. J Atheroscler Thromb. 2017;24(4):373-87.
• Korkmaz K, Gedik S, Deniz H. Can cervical blockage routinly application at carotis artery surgery? Duzce Med J. 2010;12(2):21-3.
• Erickson KM, Cole DJ. Carotid artery disease: stenting vs. endarterectomy. Br J Anaesth. 2010;105(Suppl 1):i34-49.
• Giannopoulos A, Kakkos S, Abbott A, Naylor AR, Richards T, Mikhailidis DP, et al. Long-term mortality in patients with asymptomatic carotid stenosis: implications for statin therapy. Eur J Vasc Endovasc Surg. 2015;50(5):573-82.
• Cheng SF, Velzen TJ, Gregson J, Richards T, Jäger HR, Simister R, et al. The 2nd European Carotid Surgery Trial (ECST-2): rationale and protocol for a randomized clinical trial comparing immediate revascularization versus optimized medical therapy alone in patients with symptomatic and asymptomatic carotid stenosis at low to intermediate risk of stroke. Trials. 2022;23(1):606.
• Sardar P, Chatterjee S, Aronow HD, Kundu A, Ramchand P, Mukherjee D, et al. Carotid artery stenting versus endarterectomy for stroke prevention: a meta-analysis of clinical trials. J Am Coll Cardiol. 2017;69(18):2266-75.
• McGowan J, Sampson M, Salzwedel DM, Cogo E, Foerster V, Lefebvre C. PRESS peer review of electronic search strategies: 2015 guideline statement. J Clin Epidemiol. 2016;75:40-6.
• SPACE Collaborative Group; Ringleb PA, Allenberg J, Brückmann H, Eckstein HH, Fraedrich G, et al. 30 day results from the SPACE trial of stent-protected angioplasty versus carotid endarterectomy in symptomatic patients: a randomized non-inferiority trial. Lancet. 2006;368(9543):1239-47.
• Chaturvedi S, Sacco RL. How recent data have impacted the treatment of internal carotid artery stenosis. J Am Coll Cardiol. 2015;65(11):1134-43.
• Kan X, Wang Y, Xiong B, Liang B, Zhou G, Liang H, et al. Carotid artery stenting versus carotid endarterectomy in the treatment of symptomatic and asymptomatic carotid stenosis: a systematic review and meta-analysis. J Interv Med. 2019;1(1):42-8.
• Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ. 2009;339:b2535.
• Higgins JPT, Green S, editors. Cochrane hand book for systematic reviews of interventions. Hoboken, NJ, USA: John Wiley&Sons; 2011.
• McGuinness LA, Higgins JPT. Risk-of-bias VISualization (robvis): An R package and Shiny web app for visualizing risk-of-bias assessments. Res Synth Methods. 2021;12(1):55-61.
• Alberts MJ. Results of a multicenter prospective randomized trial of carotid artery stenting vs carotid endarterectomy. Stroke. 2001;32(Suppl 1):325.
• Naylor AR, Bolia A, Abbott RJ, Pye IF, Smith J, Lennard N, et al. Randomized study of carotid angioplasty and stenting versus carotid endarterectomy: a stopped trial. J Vasc Surg. 1998;28(2):326-34.
• Brooks WH, McClure RR, Jones MR, Coleman TC, Breathitt L. Carotid angioplasty and stenting versus carotid endarterectomy: randomized trial in a community hospital. J Am Coll Cardiol. 2001;38(6):1589-95.
• Kougias P, Collins R, Pastorek N, Sharath S, Barshes NR, McCulloch K, et al. Comparison of domain-specific cognitive function after carotid endarterectomy and stenting. J Vasc Surg. 2015;62(2):355-61.
• CAVATAS investigators; Brown MM, Rogers J, Bland JM, et al. Endovascular versus surgical treatment in patients with carotid stenosis in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS): a randomized trial. Lancet. 2001;357(9270):1729-37.
• Brooks WH, McClure RR, Jones MR, Coleman TL, Breathitt L. Carotid angioplasty and stenting versus carotid endarterectomy for treatment of asymptomatic carotid stenosis: a randomized trial in a community hospital. J Neurosurg. 2004;54(2):318-25.
• Yadav JS, Wholey MH, Kuntz RE, Fayad P, Katzen BT, Mishkel GJ, et al. Protected carotid-artery stenting versus endarterectomy in high-risk patients. N Engl J Med. 2004;351(15):1493-501.
• Mannheim D, Karmeli R. A prospective randomized trial comparing endarterectomy to stenting in severe asymptomatic carotid stenosis. J Cardiovasc Surg (Torino). 2017;58(6):814-7.
• Mas JL, Chatellier G, Beyssen B, Branchereau A, Moulin T, Becquemin JP, et al. Endarterectomy versus stenting in patients with symptomatic severe carotid stenosis. N Engl J Med. 2006;355(16):1660-71.
• Liu CW, Liu B, Ye W, Wu WW, Li YJ, Zheng YH, et al. Carotid endarterectomy versus carotid stenting: a prospective randomized trial. Zhonghua Wai Ke Za Zhi. 2009;47(4):267-70. Chinese.
• Ling F, Jiao LQ. Preliminary report of trial of endarterectomy versus stenting for the treatment of carotid atherosclerotic stenosis in China (TESCAS-C). Chinese J Cerebrovasc Dis. 2006;3(1):4-8.
• Hoffmann A, Engelter S, Taschner C, Mendelowitsch A, Merlo A, Radue EW, et al. Carotid artery stenting versus carotid endarterectomy-a prospective randomized controlled single-center trial with long-term follow-up (BACASS). Schweizer Arch Neurol Psychiatr. 2008;159(2):84-9.
• Reiff T, Eckstein HH, Mansmann U, Jansen O, Fraedrich G, Mudra H, et al. Angioplasty in asymptomatic carotid artery stenosis vs. endarterectomy compared to best medical treatment: one-year interim results of SPACE-2. Int J Stroke. 2020;15(6):638-49.
• International Carotid Stenting Study investigators; Ederle J, Dobson J, Featherstone RL, Bonati LH, van der Worp HB, et al. Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): an interim analysis of a randomized controlled trial. Lancet. 2010;375(9719):985-97.
• Brott TG, Hobson RW 2nd, Howard G, Roubin GS, Clark WM, Brooks W, et al. Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med. 2010;363(1):11-23.
• Kuliha M, Roubec M, Procházka V, Jonszta T, Hrbáč T, Havelka J, et al. Randomized clinical trial comparing neurological outcomes after carotid endarterectomy or stenting. Br J Surg. 2015;102(3):194-201.
• Rosenfield K, Matsumura JS, Chaturvedi S, Riles T, Ansel GM, Metzger DC, et al. Randomized trial of stent versus surgery for asymptomatic carotid stenosis. N Engl J Med. 2016;374(11):1011-20.
• Školoudík D, Kuliha M, Hrbáč T, Jonszta T, Herzig R; SONOBUSTER Trial Group. Sonolysis in prevention of brain infarction during carotid endarterectomy and stenting (SONOBUSTER): a randomized, controlled trial. Eur Heart J. 2016;37(40):3096-102.
• Halliday A, Bulbulia R, Bonati LH, Chester J, Cradduck-Bamford A, Peto R, et al. Second asymptomatic carotid surgery trial (ACST-2): a randomised comparison of carotid artery stenting versus carotid endarterectomy. Lancet. 2021;398(10305):1065-73.
• Matsumura JS, Hanlon BM, Rosenfield K, Voeks JH, Howard G, Roubin GS, et al. Treatment of carotid stenosis in asymptomatic, non-octogenarian, standard risk patients with stenting versus endarterectomy trials. J Vasc Surg. 2022;75(4):1276-83.e1.
• White CJ. Carotid artery stenting. J Am Coll Cardiol. 2014;64(7):722-31.
• Naylor AR, Ricco JB, de Borst GJ, Debus S, de Haro J, Halliday A, et al. Management of atherosclerotic carotid and vertebral artery disease: 2017 clinical practice guidelines of the European society for vascular surgery (ESVS). Eur J Vasc Endovasc Surg. 2018;55(1):3-81.
• Vincent S, Eberg M, Eisenberg MJ, Filion KB. 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):S99-108.
• Kalender M, Uğur O, Gökmengil H, Baysal AN, Yakın Düzyol İ, Parlar H, Karaca OG. Short term outcomes of endarterectomy to asymptomatic extracranial carotid artery disease. Duzce Med J. 2020;22(2):101-4.
• Yavin D, Roberts DJ, Tso M, Sutherland GR, Eliasziw M, Wong JH. Carotid endarterectomy versus stenting: a meta-analysis of randomized trials. Can J Neurol Sci. 2011;38(2):230-5.
• Murad MH, Flynn DN, Elamin MB, Guyatt GH, Hobson RW 2nd, Erwic PJ, et al. Endarterectomy vs. stenting for carotid artery stenosis: a systematic review and meta-analysis. J Vasc Surg. 2008;48(2):487-93.