O-213 - ENDARTERECTOMY ACHIEVES LOWER STROKE AND DEATH RATES COMPARED WITH STENTING IN PATIENTS WITH ASYMPTOMATIC CAROTID STENOSIS. A SYSTEMATIC REVIEW AND META-ANALYSIS OF THE LITERATURE.

TOPIC:
Other
AUTHORS:
Alexopoulou-Prounia L. (Department of Vascular Surgery, University of Patras Medical School ~ Patras ~ Greece) , Kakkos K S. (Department of Vascular Surgery, University of Patras Medical School ~ Patras ~ Greece) , Kakisis I. (Department of Vascular Surgery, National and Kapodistrian University of Athens ~ Athens ~ Greece) , Geroulakos G. (Department of Vascular Surgery, National and Kapodistrian University of Athens ~ Athens ~ Greece)
Introduction:
It is currently unclear if carotid artery stenting (CAS) is as safe as carotid endarterectomy (CEA) for patients with significant asymptomatic stenosis. The aim of our study was to update a systematic review and meta-analysis of trials comparing CAS with CEA previously performed, showing a moderate certainty of evidence in favor of CEA regarding 30 day stroke or death rates (1).
Methods:
On January 21, 2022, an updated search for randomized controlled trials was performed in MEDLINE, SCOPUS and Cochrane CENTRAL databases with no time limits. We performed meta-analyses with risk ratios (RRs) and 95% confidence intervals (CIs). Certainty of evidence was assessed with the Grading of Recommendations Assessment, Development, and Evaluation method. The primary safety and efficacy outcome measures were stroke or death rate at 30 days and long-term ipsilateral stroke (including ipsilateral stroke and death rate at 30 days), respectively. Perioperative stroke, ipsilateral stroke, myocardial infarction (MI), and cranial nerve injury (CNI) were all secondary outcome measures.
Results:
The systematic review of the literature identified ten randomized controlled trials reporting on 7334 patients allocated into CEA (n = 3293) or CAS (n = 4041). Stroke or death rate at 30 days was significantly higher for CAS (126/3829 [3.29%]) compared with CEA (76/3219 [2.36%]; RR, 1.46; 95% CI, 1.09-1.94; P = .01, I2=0%, Figure). Also, stroke rate at 30 days was significantly higher for CAS (122/3829 [3.19%]) than for CEA (70/3219 [2.17%]; RR, 1.53; 95% CI, 1.14-2.07; P = .005; I2 = 0%). MI at 30 days was significantly lower for CAS (16/3665 [0.44%]) compared with CEA (29/3061 [0.95%]; RR, 0.45; 95% CI, 0.24-0.85; P = .01; I2 = 0%); however, CNI at 30 days was significantly lower for CAS (2/3447 [0.06%]) than for CEA (129/2849 [4.53%]; RR, 0.02; 95% CI, 0.01-0.07; P < .00001), with medium level of heterogeneity beyond chance I2 = 40%. Regarding the long-term outcome of stroke or death rate at 30 days plus ipsilateral stroke during follow-up, this was significantly higher for CAS (174/3984 [4.37%]) than for CEA (105/3244 [3.24%]; RR, 1.42; 95% CI, 1.11-1.80; P = .005; I2 = 0%). Certainty of evidence for all stroke outcomes apart from ipsilateral stroke was graded high. Certainty of evidence for ipsilateral stroke was graded moderate, and for MI low (Table).
Conclusion:
Among patients with asymptomatic stenosis undergoing carotid intervention, there is high-certainty evidence to suggest that CEA had significantly lower 30-day stroke and also stroke or death rates compared with CAS at the cost of higher CNI. CAS has significantly lower rates MI at 30 days, compared to CEA. The long-term efficacy of CEA in ipsilateral stroke prevention, taking into account perioperative stroke and death, was preserved during follow-up.
References:
1. Kakkos SK, Kakisis I, Tsolakis IA, Geroulakos G. Endarterectomy achieves lower stroke and death rates compared with stenting in patients with asymptomatic carotid stenosis. J Vasc Surg. 2017;66(2):607-617. doi:10.1016/j.jvs.2017.04.053.
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