Carotid Artery Stenting versus Endarterectomy: A Systematic Review

For about 2 decades, investigators have been comparing carotid endarterectomy with carotid artery stenting in regard to their effectiveness and safety in treating carotid artery stenosis. We conducted a systematic review to summarize and appraise the available evidence provided by randomized trials, meta-analyses, and registries comparing the clinical outcomes of the 2 procedures. We searched the MEDLINE, SciVerse Scopus, and Cochrane databases and the bibliographies of pertinent textbooks and articles to identify these studies.The results of clinical trials and, consequently, the meta-analyses of those trials produced conflicting results regarding the comparative effectiveness and safety of carotid endarterectomy and carotid stenting. These conflicting results arose because of differences in patient population, trial design, outcome measures, and variability among centers in the endovascular devices used and in operator skills. Careful appraisal of the trials and meta-analyses, particularly the most recent and largest National Institutes of Healthsponsored trial (the Carotid Revascularization Endarterectomy vs Stenting Trial [CREST]), showed that carotid stenting and endarterectomy were associated with similar rates of death and disabling stroke. Within the 30-day periprocedural period, carotid stenting was associated with higher risks of stroke, especially for patients aged >70 years, whereas carotid endarterectomy was associated with a higher risk of myocardial infarction. The slightly higher cost of stenting compared with endarterectomy was within an acceptable range by cost-effectiveness standards. We conclude that carotid artery stenting is an equivalent alternative to carotid endarterectomy when patient age and anatomy, surgical risk, and operator experience are considered in the choice of treatment approach.     

Carotid Artery Stenting Versus Carotid Endarterectomy: Post CREST

The risk of stroke associated with carotid artery stenosis can be reduced with carotid endarterectomy or carotid artery stenting in carefully selected patients. While surgery has been the traditional treatment there have been many trials comparing carotid endarterectomy with carotid artery stenting, and stenting has shown promising results for certain patient populations. This article reviews the natural history of carotid artery stenosis, the data supporting carotid endarterectomy, trials directly comparing surgery to stenting, and current recommendations for each modality.     

颈动脉支架置入术会取代颈动脉内膜切除术吗?

多年来,颈动脉内膜切除术(CEA)一直被视为重度颈动脉狭窄患者治疗的"金标准",但随着颈动脉支架置入术(CAS)的发展,逐渐使CEA的"金标准"地位受到挑战,甚至有人提出用CAS代替CEA.近年来陆续发表了有关两种治疗方式的对比研究,但对相关研究结果的解读,以及各项研究间的结果却并不一致.文章就这些方面的争议进行了分析.     

颈动脉狭窄的干预治疗:支架还是内膜剥脱?

颈动脉狭窄是卒中的常见原因.颈动脉血管成形和支架正成为颈动脉内膜剥脱术后治疗颈动脉狭窄的一种有效方法.两种方法孰优孰劣是近来争论的焦点,现通过比较近来对颈动脉内膜剥脱术和颈动脉血管成形和支架术对比的试验研究,认为未来几年是评价两种方法的重要时期.     

Carotid Artery Stenting: Update

“Extracranial carotid artery stenosis is responsible for approximately 20–30% of ischemic strokes. Traditionally, carotid artery stenosis has been treated with carotid endarterectomy. However, the low periprocedural complication rate and the mid term durability of carotid artery stenting has made it a competitive alternative treatment strategy. This update reviews the technical aspects of carotid artery stenting, clinical data supporting carotid artery stenting‐particularly in high risk patients, and the complications associated with carotid artery stenting.”     

Carotid Endarterectomy versus Carotid Stenting or Best Medical Treatment in Asymptomatic Patients with Significant Carotid Stenosis: A meta-analysis

BackgroundThis meta-analysis aimed to evaluate randomized trials (RTs) that compare outcomes among asymptomatic patients with significant carotid stenosis undergoing carotid endarterectomy (CEA) versus carotid stenting (CAS) or best medical treatment (BMT).Material and methodsThe Pubmed, Embase, Scopus and Cochrane Library databases were systematically searched to identify eligible studies. Data were analyzed by using the StatsDirect Statistical software (Version 2.8.0, StatsDirect Ltd). Odds ratios (OR) were used to determine effect size, along with 95% confidence interval (CI). PRISMA guidelines for conducting meta-analyses were utilized.ResultsOverall, 10 RTs including 8771 asymptomatic patients were evaluated. Compared to CAS, 30-day all stroke risk was found to be lower after CEA (pooled OR = 0.56; CI 95% [0.312–0.989]; P = 0.046). However, other early and late outcomes were not different between CEA and CAS. Furthermore, 30-day all stroke (pooled OR = 3.43; CI 95% [1.810–6.510]; P = 0.0002), death (pooled OR = 4.75; CI 95% [1.548–14.581]; P = 0.007) and myocardial infarction (MI) (pooled OR = 9.18; CI 95% [1.668–50.524]; P = 0.011) risks were higher after CEA compared to BMT, as expected. Additionally, 30-day all stroke/death and all stroke/death/MI risks were higher after CEA compared to BMT as well. Regarding long-term results, ipsilateral stroke risk was lower after CEA compared to BMT (pooled OR = 0.46; CI 95% [0.361–0.596]; P < 0.0001) although death due to stroke risk was not different (pooled OR = 0.57; CI 95% [0.223–1.457]; P = 0.240). Unfortunately, no study comparing CAS to BMT was found.ConclusionsCEA is associated with a lower early all stroke risk compared to CAS although other early or late outcomes did not show any difference between the two methods. Additionally, CEA seems to have a benefit over BMT against long-term ipsilateral stroke, although early outcomes are worse after CEA. No studies are available comparing CAS to BMT alone.     

Systematic Review and Meta-Analysis of Carotid Artery Stenting Versus Endarterectomy for Carotid Stenosis: A Chronological and Worldwide Study

There are disparities among the results of meta-analyses under different circumstances of carotid artery stenting (CAS) versus endarterectomy (CEA) for carotid stenosis. This study aimed to assess the efficacies of CAS and CEA for carotid stenosis at 5-year intervals and worldwide.Comparative studies simultaneously reporting CAS and CEA for carotid stenosis with at least 10 patients in each group were identified by searching PubMed and Embase in accordance with preferred reporting items for systematic reviews and meta-analyses guidelines, and by reviewing the reference lists of retrieved articles.The studies were stratified into different subgroups according to the publication year, location in which the study was mainly performed, and randomized and nonrandomized study designs.Thirty-five comparative studies encompassing 27,525 patients were identified. The risk ratios (RRs) of stroke/death when CAS was compared with CEA within 30 d of treatment were 1.51 (95% CI 1.32–1.74, P < 0.001) for overall, 1.50 (95% CI 1.14–1.98, P = 0.004) from 2011 to 2015, 1.61 (95% CI 1.35–1.91, P < 0.001) from 2006 to 2010, 1.59 (95% CI 1.27–1.99, P < 0.001) in North America, 1.50 (95% CI 1.24–1.81, P < 0.001) in Europe, 1.63 (95% CI 1.31–2.02, P < 0.001) for randomized, and 1.44 (95% CI 1.20–1.73, P < 0.001) for nonrandomized comparative studies. CEA decreased the risks of transient ischemic attack at 30 d (RR: 2.07, 95% CI 1.50–2.85, P < 0.001) and restenosis at 1-year (RR: 1.97, 95% CI 1.28–3.05, P = 0.002). Data from follow-up showed that the RRs of stroke/death were 0.74 (95% CI 0.55–0.99, P = 0.04) at 1 year, 1.24 (95% CI 1.04–1.46, P = 0.01) at 4 year, and 2.27 (95% CI 1.39–3.71, P = 0.001) at 10 year. This systematic review, compared with those of other meta-analyses, included all available comparative studies and analyzed them at 5-year intervals, in different continents, and under different study designs. Current evidence suggests that the efficacy of CEA is superior to CAS for freedom from stroke/death within 30 d, especially from 2006 to 2015, in North America and Europe. Meanwhile, the superiority was also observed for restenosis at 1-year, transient ischemic attack within 30 d, and stroke/death at 4- and 10-year follow-ups.     

Carotid artery disease: Stenting versus endarterectomy

Atherosclerotic carotid artery stenosis is a major cause of disabling stroke or death. Although carotid endarterectomy (CEA) is currently considered to be the standard of care for patients with a severe symptomatic stenosis and selected patients with an asymptomatic carotid stenosis, carotid angioplasty and stenting (CAS) is increasingly being used as an alternative treatment modality. This article briefly summarizes the current trial data on CEA and CAS. More importantly, potential risk factors for CEA and CAS are reviewed and the complementary role of these techniques in the management of the individual patient is discussed.     

External Carotid Artery to Internal Carotid Artery Transposition with Patch Resection to Treat an Infected Carotid Endarterectomy Dacron Patch: A Novel Technique

IntroductionProsthetic patch infection after carotid endarterectomy is a rare but potentially devastating complication. The published literature generally supports patch resection with vein patch closure or venous interposition grafting.ReportOur patient presented nine years post surgery with swelling and discharge related to the operative scar. The prosthetic patch and internal carotid artery were resected and the external carotid artery was transposed to the distal internal carotid artery to restore cerebral perfusion.DiscussionThis case highlights a mode of late presentation of patch infection and introduces a novel surgical technique that has not been described in the contemporary literature reviews.     

Cerebral Embolic Lesions Detected With Diffusion-Weighted Magnetic Resonance Imaging Following Carotid Artery Stenting: A Meta-Analysis of 8 Studies Comparing Filter Cerebral Protection and Proximal Balloon Occlusion

ObjectivesThe aim of this meta-analysis was to evaluate and compare the efficacy of the 2 different neuroprotection systems in preventing embolization during carotid artery stenting (CAS), as detected by diffusion-weighted magnetic resonance imaging (DW-MRI).BackgroundData from randomized and nonrandomized studies comparing both types of embolic protection devices revealed contrasting evidence about their efficacy in neuroprotection, as assessed by the incidence of new ischemic lesions detected by DW-MRI.MethodsEight studies, enrolling 357 patients, were included in the meta-analysis. Our study analyzed the incidence of new ischemic lesions/patient, comparing filter cerebral protection and proximal balloon occlusion.ResultsFollowing CAS, the incidence of new ischemic lesions/patient detected by DW-MRI was significantly lower in the proximal balloon occlusion group (effect size [ES]: −0.43; 95% confidence interval [CI]: −0.84 to −0.02, I² = 70.08, Q = 23.40). Furthermore, following CAS, the incidence of lesions at the contralateral site was significantly lower in the proximal protection group (ES: −0.50; 95% CI: −0.72 to −0.27, I² = 0.00, Q = 3.80).ConclusionsOur meta-analysis supports the concept that the use of proximal balloon occlusion compared with filter cerebral protection is associated with a reduction of the amount of CAS-related brain embolization. The data should be confirmed by a randomized clinical trial.     

Carotid Artery Stenting: A Vascular Surgeon-Endovascular Specialist's Perspective

Endovascular interventions were developed to provide minimally invasive alternatives to standard surgical therapies. Where an endoluminal technique has the potential to supplant its surgical predecessor, the rival must prove itself against the gold standard in terms of outcome, complications, and durability. In the case of carotid stenting, the stroke risk reduction data for carotid endarterectomy gathered from recent randomized trials appear to be unassailable. In the face of this challenge, why would we pursue an endoluminal alternative? Would the investment in resources and device development result in benefit to the patient? In this perspective, an endovascular surgeon proposes several possible case scenarios appropriate to carotid stenting and reviews progress to date on the investigation of this therapeutic alternative.