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.