Home > DARE Reviews > Carotid artery stenting versus carotid...

PubMed Health. A service of the National Library of Medicine, National Institutes of Health.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet].

Carotid artery stenting versus carotid endarterectomy: a comprehensive meta-analysis of short-term and long-term outcomes

KP Economopoulos, TN Sergentanis, G Tsivgoulis, AD Mariolis, and C Stefanadis.

Review published: 2011.

Link to full article: [Journal publisher]

CRD summary

The authors concluded that carotid endarterectomy seems superior to carotid artery stenting, but there may be patient subgroups with equivalent results. Unclear trial quality and significant clinical variation among studies mean that the authors’ suggestion to consider the results as hypothesis-generating and not definitive evidence should be heeded.

Authors' objectives

To compare short-term and long-term outcomes between carotid artery stenting and carotid endarterectomy for the treatment of severe carotid artery stenosis.

Searching

MEDLINE was searched between 1990 and May 2010. There were no language restrictions. Search terms were reported. Abstracts and conference proceedings from the American College of Cardiology, European Society of Cardiology, Transcatheter Cardiovascular Therapeutics and American Heart Association were searched between 2006 and 2009. Reference lists of relevant reviews and articles were searched manually.

Study selection

Randomised controlled trials (RCTs) that compared carotid artery stenting with carotid endarterectomy for the treatment of symptomatic and asymptomatic patients with unilateral or bilateral carotid artery stenosis were eligible for inclusion. All endovascular techniques and open surgical treatment approaches were eligible. Studies were required to report short-term and long-term outcomes: death, stroke, myocardial infarction, death or stroke, death or ipsilateral stroke, death or disabling stroke, death or stroke or myocardial infarction. Short-term outcomes included cranial nerve injury.

Most of the included studies were conducted in USA and Europe. The mean age of patients ranged from 63 to 73 years. Some patients had hypertension, diabetes, hyperlipidaemia/dyslipidaemia or cardiovascular disease at baseline. Some studies allowed distal protection devices. Antiplatelets were administered in most studies. Where reported, outcome definitions varied between studies.

Two reviewers independently screened studies for selection.

Assessment of study quality

The authors did not state that they assessed study quality.

Data extraction

Two reviewers independently extracted the number of events for short-term (30 days) outcomes to calculate odds ratios (ORs) and associated 95% confidence intervals (CIs). The number of events (or hazard ratios, where these were reported) were extracted for long-term (≥1 year) outcomes to calculate odds ratios or hazard ratios, and their 95% CIs. Analyses were performed on an intention-to-treat (ITT) basis. Where zero events were reported, 0.5 was added.

Methods of synthesis

A fixed-effect model, or random effects model where heterogeneity was evident, was used to calculate pooled odds ratios and hazard ratios, and 95% CIs. Statistical heterogeneity was assessed using the Cochran Q and I2.

Post hoc meta-regression was conducted where odds ratios were statistically significant, to assess the impact of patient status (symptomatic or asymptomatic), use of distal protection devices in the carotid artery stenting patients, early termination of the trial, patients' mean age, area of study origin (USA versus other), commercial funding and year of publication. Subgroup analysis was performed to assess age cut-off (<68 years vs >68 years). Sensitivity analysis was performed to assess the impact of different outcome definitions on the results.

Publication bias was assessed through visual inspection of funnel plots (where there were up to nine RCTs) or using Egger’s test.

Results of the review

Thirteen RCTs (20 articles, 3,723 participants who underwent carotid artery stenting and 3,754 who underwent carotid endarterectomy) were included in the review. Follow-up ranged from 30 days to 5.5 years. Six trials were stopped early, three due to inferiority of carotid artery stenting.

Short-term outcomes: Carotid artery stenting significantly increased the risk of stroke (OR 1.53, 95% CI 1.23 to 1.91; 11 RCTs, I2=24.1%) and death or stroke (OR 1.54, 95% CI 1.25 to 1.89; 12 RCTs, I2=33.5%). By contrast, carotid endarterectomy was associated with significantly increased risk of myocardial infarction (OR 0.48, 95% CI 0.30 to 0.78; nine RCTs, I2=0%) and cranial nerve injury (OR 0.09, 95% CI 0.05 to 0.16; 11 RCTs, I2=0%). No other findings were statistically significant.

Long-term outcomes: Patients who underwent carotid artery stenting remained at significantly greater risk of stroke (OR 1.37, 95% CI 1.13 to 1.65; nine RCTs, I2=0%) and death or stroke (OR 1.25, 95% CI 1.06 to 1.48; 10 RCTs, I2=0%) and these findings were confirmed using pooled hazard ratios. There were no statistically significant differences in risk of death and death or disabling stroke.

Meta-regression did not identify any significant moderator variables. Subgroup analysis showed that risk of long-term stroke in patients aged over 68 was statistically significantly greater in patients who underwent carotid artery stenting; there was no difference in patients aged under 68 years. Sensitivity analysis resulted in a non-significant risk difference for the long-term outcome of death or stroke.

There was evidence of publication bias for short-term risk of death on visual inspection of a funnel plot.

Authors' conclusions

Carotid endarterectomy seems superior to carotid artery stenting, but there may be population subgroups, particularly younger patients, in whom the results are equivalent.

CRD commentary

The review question and supporting inclusion criteria were clearly stated. One electronic database and other appropriate sources were searched without language restrictions. No apparent attempts were made to locate unpublished data, so potentially relevant data may have been missed. Publication bias was formally assessed and there was a suggestion of bias for one outcome. The quality of the trials was unclear as no apparent formal assessment was undertaken. Study screening and data extraction were performed in duplicate, which reduced potential for reviewer error and bias. The authors acknowledged the clinical heterogeneity among trials and made attempts to investigate this. They also acknowledged the low statistical power in some studies and early termination of some studies.

Unclear trial quality and significant clinical variation among studies mean that the authors’ suggestion to consider the results as hypothesis-generating and not definitive evidence should be heeded.

Implications of the review for practice and research

Practice: The authors stated that the results should be considered as hypothesis-generating and not as definitive evidence.

Research: The authors stated that long-term follow-up studies were needed to assess the effects of age on long-term outcomes.

Funding

None stated.

Bibliographic details

Economopoulos KP, Sergentanis TN, Tsivgoulis G, Mariolis AD, Stefanadis C. Carotid artery stenting versus carotid endarterectomy: a comprehensive meta-analysis of short-term and long-term outcomes. Stroke 2011; 42(3): 687-692. [PubMed: 21233476]

Indexing Status

Subject indexing assigned by NLM

MeSH

Carotid Stenosis /epidemiology /surgery; Endarterectomy, Carotid /adverse effects /trends; Humans; Randomized Controlled Trials as Topic /trends; Stents /adverse effects /trends; Stroke /epidemiology /etiology; Time Factors; Treatment Outcome

AccessionNumber

12011001884

Database entry date

12/03/2012

Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.

CRD has determined that this article meets the DARE scientific quality criteria for a systematic review.

Copyright © 2014 University of York.

PMID: 21233476

Download

PubMed Health Blog...

read all...

Recent Activity

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

See more...