A Meta-analysis Of Carotid Endarterectomy Versus Carotid Artery Stenting For Carotid Artery Stenosis

Objective: To evaluate the safety and efficacy of carotid endarterectomy(CEA) versus carotid artery stenting(CAS) for carotid artery stenosis.Methods: We searched electronic databases(MEDLINE, Pub Med, Cochrane Library, VIP, CNKI and CBM) and relevant articles for all prospective, randomized, controlled trials(RCTS) involving carotid artery stenosis patients who underwent CAS or CEA with English and Chinese, focusing on studies published in 1995 to 2015.Review Manager 5.3 was used for analyzing data of intention to treat(ITT).Results: Fifteen prospective RCTS totaling 7693 participants(3832 participants were randomized to CEA and 3861 randomized to CAS) with symptom or asymptomatic carotid artery stenosis were included in the Meta—analysis. Results of the Meta-analysis are as follows. 1. The short-term risks of postoperative for serious adverse events: The most important index is 30-day relative risks for stroke, myocardial infarction, or death. There were significantly less 30-day relative risks after CEA than after CAS for stroke, myocardial infarction, or death(merger effect value RR=0.71,95%CI:[0.59,0.87],P=0.0009). The heterogeneity between the studies may be accepted, and the result is less sensitive, robust and reliable. In addition, we found no significant publication bias. Further analysis of the serious adverse events are as follows: 1. There were significantly less 30-day relative risks after CEA than after CAS for stroke(merger effect value RR=0.64,95%CI:[0.51,0.79],P<0.0001). The heterogeneity between the studies may be accepted, and the result is less sensitive, robust and reliable. 2. There were significantly less 30-day relative risks after CEA than after CAS for death(merger effect value RR=0.57,95%CI:[0.35,0.93],P=0.02). The heterogeneity between the studies may be accepted, and the result is less sensitive, robust and reliable. 3. There were more 30-day relative risks after CEA than after CAS for myocardial infarction(merger effect value RR=1.87, 95%CI : [1.13, 3.07], P=0.01). The heterogeneity between the studies may be accepted, and the result is less sensitive, reliable. 2. The short-term risks of postoperative for mild adverse events: The 30-day relative risks of cranial neuropathy(merger effect value RR=17.55,95%CI:[7.45,41.35],P<0.00001) was significantly less after CAS than after CEA.The heterogeneity between the studies may be accepted, and the result is less sensitive, robust and reliable. 3. The mid-term efficacy of postoperative: The relative risks of stroke or death at 1 year(merger effect value RR=0.86,95%CI:[0.61,1.21],P=0.39) after the procedures did not differ significantly between CEA and CAS.The heterogeneity between the studies may be accepted, and the result is less sensitive, robust and reliable. 4. The long-term efficacy of postoperative: The relative risks of stroke or death at 10 year(merger effect value RR=0.86,95%CI:[0.61,1.21],P=0.39) was significantly less after CAS than after CEA.The heterogeneity between the studies may be accepted, but the results are high sensitivity, low robustness.Conclusion: The results suggest that CEA was found to be superior to CAS for short-term outcomes and long term outcomes, but the difference was not significant for intermediate outcomes. As a result, CEA remains the ‘‘gold standard’’ treatment for suitable symptomatic or asymptomatic carotid stenosis. In addition, CAS only can be used as an alternative supplementary therapy in patients with high risk of preoperative coronary artery disease.