Endarterectomy vs. Stenting in Asymptomatic Carotid Artery Stenosis

The comparative efficacy and safety of carotid stenting vs. endarterectomy in asymptomatic carotid stenosis patients remains controversial and, what is worse, consensus seems unlikely in the near future. Given the lack of definite evidence, several meta-analyzis and systematic reviews have been produced in an attempt to shed some light on this matter.

This study included all controlled and randomized trials comparing both techniques in asymptomatic patients using a pre-specified protocol.

Five controlled studies met the inclusion criteria, adding up more than 3,000 patients.

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The pooled incidence of any periprocedural stroke (RR 1.84; CI 95%, 0.99–3.40), periprocedural nondisabling stroke (RR 1.95; CI 95%, 0.98 – 3.89) and any periprocedural stroke or death (RR 1.72; CI 95%, 0.95 – 3.11) show a tendency against stenting. This tendency was observed in periprocedural events, with no difference in stroke at long term (RR 1.24; CI 95%, 0.76 – 2.03) or with the composite of periprocedural stroke, death, MI or ipsilateral stroke at long term (RR 0.92; IC 95%, 0.70–1.21).

Conclusion

The best revascularization technique for patients with asymptomatic carotid stenosis continues to be a matter of debate, despite the higher incidence of periprocedural stroke against stenting seems to tilt the scales in favor of endarterectomy.

Editorial Comment

The estimated risk of ipsilateral stroke for asymptomatic patients with a ≥50% stenosis to the internal carotid artery is as low as 0.5 or 1% per year. Hence, in order to show the benefits of revascularization, if any, we would need long term follow up.

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The best medical treatment should be prescribed to these patients, but randomized studies comparing stenting vs. endarterectomy were carried out mostly between 1980 and 2000. Without a shadow of a doubt, current medical treatments are highly superior to any medical treatment two decades old, which is why we should consider a third option to treat these patients, one that the original studies had not considered.

At present, there are two randomized studies in progress (SPACE-II y CREST-II) that will provide valuable data on the comparative safety and efficacy of the best medical treatment vs. stenting + the best medical treatment vs. endarterectomy + the best medical treatment.

Original title: Carotid Stenting Versus Endarterectomy for Asymptomatic Carotid Artery Stenosis. A Systematic Review and Meta-Analysis.

Reference: Paola Moresoli et al. Stroke. 2017 Aug;48(8):2150-2157.

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