Angioplasty vs Carotid Endarterectomy: Systematic Review and Meta-Analysis of Randomized Clinical Trials

Courtesy of Dr. Juan Manuel Pérez.

Carotid stenosis is a major risk factor for stroke. Its treatment includes carotid endarterectomy (CEA), which is considered the gold standard, and carotid artery stenting (CAS), as a minimally invasive alternative. Given the disparate results in terms of efficacy and safety, this study conducted a systematic review and meta-analysis of randomized clinical trials comparing both techniques.

Researchers included a total of 28 randomized clinical trials (RCTs), with more than 22,000 patients with carotid stenosis (generally defined as ≥50% in symptomatic cases or ≥70% in asymptomatic cases). The mean age ranged from 67 to 71 years, with a similar distribution between groups. CAS procedures were mainly performed using a transfemoral approach, with self-expanding nitinol stents and, in the more recent studies, with the systematic use of embolic protection devices.

The mortality analysis (14 studies, 14,669 participants) showed no significant differences between the two groups (risk ratio [RR] 1.267; 95% confidence interval [CI] 0.919–1.746; p=0.149). CAS was associated with a higher risk of stroke (20 studies, 22,005 patients; RR 1.490; 95% CI 1.282–1.731; p<0.001) and with a higher borderline risk of restenosis (4 studies, 3166 patients; RR 1.257; 95% CI 1.000–1.578; p=0.050).

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In contrast, the incidence of acute myocardial infarction (AMI) was lower with CAS (11 studies, 14,621 patients; RR 0.476; 95% CI 0.341–0.664; p<0.001), and so was cranial nerve palsy (7 studies, 6880 patients; RR 0.079; 95% CI 0.042–0.149; p<0.001). There were no significant differences regarding transient ischemic attack (RR 0.919; 95% CI 0.806–1.049; p=0.212), pulmonary embolism (RR 0.544; 95% CI 0.193–1.534; p=0.250), or the need for target-vessel revascularization (RR 0.499; 95% CI 0.223–1.115; p=0.090).

Of note, in several older RCTs (ICSS, SPACE, EVA-3S), open-cell stents were used, sometimes without embolic protection, which is associated with a higher risk of embolization and worse outcomes. By contrast, more recent studies such as CREST, ACT I, or ACST-2 used closed- or fine-cell stents, along with mandatory embolic protection, which helped improve the safety of CAS. The authors of this meta-analysis emphasize that technological evolution partially explains the heterogeneity observed between older and more recent trials.

Conclusión

In conclusion, CAS is associated with a lower risk of AMI and cranial nerve injury, although with an increased risk of stroke and a trend toward higher restenosis. Nevertheless, the addition of closed-cell stents and the systematic use of embolic protection devices in recent studies suggest a progressive improvement in procedural safety. These findings underscore the need to individualize the therapeutic decision, taking into account both the patient’s clinical profile and the availability of state-of-the-art technology and operator experience.

Original Title: Carotid Artery Stenting Versus Carotid Endarterectomy for Carotid Artery Stenosis: Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Reference: Guangxu Chu, Lifeng Cheng, Kai Zhang. Catheterization and Cardiovascular Interventions, 2025; 1–22.