Is carotid endarterectomy more effective and safer than carotid artery stenting in asymptomatic patients with carotid artery stenosis?

Oy. Somebody should get paid big bucks to help patients with asymptomatic carotid stenosis decide between carotid endarterectomy (CEA) and carotid artery stenting (CAS). The trade-offs are fewer strokes with CEA and fewer nerve palsies and myocardial infarctions with CAS. Too bad the studies did not include medically managed patients. Overall, these data suggest the need for long and careful discussions with patients about the trade-offs and uncertainties of both procedures. (LOE = 1a-)

Moresoli P, Habib B, Reynier P, Secrest MH, Eisenberg MJ, Filion KB. Carotid stenting versus endarterectomy for asymptomatic carotid artery stenosis: a systematic review and meta-analysis. Stroke 2017;48(8):2150-2157.  [PMID:28679848]

Systematic review

Government

Inpatient (any location) with outpatient follow-up

These Canadian authors combed several databases and registries using a sensible search strategy to identify randomized controlled trials that compared CEA and CAS in asymptomatic patients with carotid artery stenosis. The studies had to be published in English or in French (Canada is a bilingual nation, so this seems convenient). Two authors independently assessed studies for inclusion and resolved disagreements by consensus. Additionally 2 authors assigned each study's potential for bias as "unclear, low, or high risk of bias" in 6 discrete methodological areas. They resolved disagreements by consensus with a third party. Ultimately the authors included 5 trials with 3019 asymptomatic patients (n = 1881 for CAS; n = 1138 for CEA). The studies included heterogeneous groups of patients with regard to degree of stenosis, age, and presence of high-risk criteria. The average follow-up in the studies ranged from 30 days to 10 years. Only one of the trials exclusively recruited asymptomatic patients. In every trial, patients received aspirin or clopidogrel before surgery. Overall, the risk of bias in the studies was moderate to low. For the most part, the data demonstrate no statistically significant differences in long-term outcomes (ie, stroke, death, or myocardial infarction). Although the periprocedural outcomes of stroke and death favored CEA (number needed to treat [NNT] = 82 for the combination; NNT = 79 for any stroke), those data are of borderline statistical significance. However, patients undergoing CAS were far less likely to experience a cranial nerve palsy (NNT = 33; 95% CI 23 - 47) and showed a similarly borderline reduction in periprocedural myocardial infarction (NNT = 104). The authors provided no data on medically managed patients. Several organizations, including the American Heart Association, recommend medical management as an option, especially for patients with low-grade stenosis and at higher risk of surgical complications.