Meta-Analysis of RCTs Compares Long-Term Outcomes of CAS and CEA

October 30, 2015—Kristian B. Filion, PhD, from the Division of Clinical Epidemiology at McGill University in Montreal, Quebec, led a study that compared the safety and efficacy of carotid artery stenting (CAS) with those of carotid endarterectomy (CEA), with a particular focus on long-term outcomes, via a meta-analysis of randomized controlled trials (RCTs). The findings were recently published by Sophie Vincent, et al in Circulation: Cardiovascular Quality and Outcomes (2015;8:S99–S108).

The McGill University investigators systematically searched PubMed, EMBASE, MEDLINE, and the Cochrane Library for RCTs with 50 or more patients that compared CAS with CEA in patients with carotid stenosis. Periprocedural and long-term outcomes were assessed, with data pooled across RCTs using random-effects models. 

Eight RCTs were included in the meta-analysis (n = 7,091), with follow-up ranging from 2 to 10 years. 

As summarized in Circulation: Cardiovascular Quality and Outcomes, CAS compared to CEA was associated with an increased risk of periprocedural stroke (relative risk, 1.49; 95% confidence interval [CI], 1.11 to 2.01; risk difference, 1.7%; 95% CI, 0.3 to 3.0) but a decreased risk of periprocedural myocardial infarction (relative risk, 0.47; 95% CI, 0.29 to 0.78; risk difference, −0.4%; 95% CI, −0.8% to 0.1%). 

During long-term follow-up, stenting was associated with an increased risk of stroke (relative risk, 1.36; 95% CI, 1.16 to 1.61) and a composite endpoint of ipsilateral stroke, periprocedural stroke, or periprocedural death (relative risk, 1.45; 95% CI, 1.20 to 1.75).

Although CAS has more favorable periprocedural outcomes with respect to myocardial infarction, the observed increased risk of stroke and death throughout follow-up with CAS suggests that CEA remains the treatment of choice for carotid stenosis, concluded the investigators.