Korean Circ J.  2020 Apr;50(4):330-342. 10.4070/kcj.2019.0125.

Role of Carotid Artery Stenting in Prevention of Stroke for Asymptomatic Carotid Stenosis: Bayesian Cross-Design and Network Meta-Analyses

Affiliations
  • 1Department of Cardiology in Internal Medicine, School of Medicine, Chungnam National University, Chungnam National University Hospital, Daejeon, Korea. myheart@cnu.ac.kr
  • 2Department of Cardiology, Daegu Fatima Hospital, Daegu, Korea.
  • 3Department of Statistics, Kyungpook National University, Daegu, Korea.
  • 4Division of Cardiology, Department of Internal Medicine, Korea University Medical Center Anam Hospital, Seoul, Korea.

Abstract

BACKGROUND AND OBJECTIVES
There is insufficient evidence regarding the optimal treatment for asymptomatic carotid stenosis.
METHODS
Bayesian cross-design and network meta-analyses were performed to compare the safety and efficacy among carotid artery stenting (CAS), carotid endarterectomy (CEA), and medical treatment (MT). We identified 18 studies (4 randomized controlled trials [RCTs] and 14 nonrandomized, comparative studies [NRCSs]) comparing CAS with CEA, and 4 RCTs comparing CEA with MT from MEDLINE, Cochrane Library, and Embase databases.
RESULTS
The risk for periprocedural stroke tended to increase in CAS, compared to CEA (odds ratio [OR], 1.86; 95% credible interval [CrI], 0.62–4.54). However, estimates for periprocedural myocardial infarction (MI) were quite heterogeneous in RCTs and NRCSs. Despite a trend of decreased risk with CAS in RCTs (OR, 0.70; 95% CrI, 0.27–1.24), the risk was similar in NRCSs (OR, 1.02; 95% CrI, 0.87–1.18). In indirect comparisons of MT and CAS, MT showed a tendency to have a higher risk for the composite of periprocedural death, stroke, MI, or nonperiprocedural ipsilateral stroke (OR, 1.30; 95% CrI, 0.74–2.73). Analyses of study characteristics showed that CEA-versus-MT studies took place about 10-year earlier than CEA-versus-CAS studies.
CONCLUSIONS
A similar risk for periprocedural MI between CEA and CAS in NRCSs suggested that concerns about periprocedural MI accompanied by CEA might not matter in real-world practice when preoperative evaluation and management are working. Maybe the benefits of CAS over MT have been overestimated considering advances in medical therapy within10-year gap between CEA-versus-MT and CEA-versus-CAS studies.

Keyword

Carotid artery stenosis; Carotid endarterectomy
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