Optimal Management of Asymptomatic Carotid Artery Stenosis: A Systematic Review and Network Meta-Analysis

Sara A Gasior; John P M O'Donnell; Matthew Davey; James Clarke; Amirhossein Jalali; Éanna Ryan; Thomas M Aherne; Stewart R Walsh

doi:10.1016/j.ejvs.2023.01.020

Optimal Management of Asymptomatic Carotid Artery Stenosis: A Systematic Review and Network Meta-Analysis

Eur J Vasc Endovasc Surg. 2023 May;65(5):690-699. doi: 10.1016/j.ejvs.2023.01.020. Epub 2023 Jan 20.

Authors

Sara A Gasior¹, John P M O'Donnell², Matthew Davey³, James Clarke⁴, Amirhossein Jalali⁵, Éanna Ryan⁴, Thomas M Aherne⁶, Stewart R Walsh²

Affiliations

¹ Department of Vascular Surgery, University Hospital Galway, Galway, Ireland. Electronic address: saragasior@gmail.com.
² Department of Vascular Surgery, University Hospital Galway, Galway, Ireland; Lambe Institute for Translational Discipline of Surgery, National University of Ireland, Galway, Ireland.
³ Lambe Institute for Translational Discipline of Surgery, National University of Ireland, Galway, Ireland; Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland.
⁴ Lambe Institute for Translational Discipline of Surgery, National University of Ireland, Galway, Ireland.
⁵ School of Mathematical Sciences, University College Cork, Cork, Ireland.
⁶ Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland.

PMID: 36682406
DOI: 10.1016/j.ejvs.2023.01.020

Abstract

Objective: Management of asymptomatic carotid artery stenosis (ACAS), including carotid endarterectomy (CEA), carotid artery stenting (CAS), and best medical treatment (BMT), remains inconsistent in current practice. Early studies reported a benefit of CEA vs. BMT; however, the current risk-benefit profile of invasive therapy lacks consensus. By evaluating the effects of modern BMT vs. invasive intervention on patient outcomes, this study aimed to influence the future management of ACAS.

Methods: A systematic review and series of network meta-analyses were performed assessing peri-operative (within 30 days) and long term (30 days - 5 years) stroke and mortality risk between ACAS interventions. Total stroke, major, minor, ipsilateral, and contralateral stroke subtypes were assessed independently. Traditional (pre-2000) and modern (post-2000) BMT were compared to assess clinical improvements in medical therapy over the previous two decades. Risks of myocardial infarction (MI) and cranial nerve injury (CNI) were also assessed.

Results: Seventeen reports of 14 310 patients with > 50% ACAS were included. CEA reduced the odds of a peri-operative stroke event occurring vs. CAS (odds ratio [OR] 1.6, 95% confidence interval [CI] 1.1 - 2.2 [0 - 20 fewer/1 000]). CEA and CAS reduced the long term odds of minor strokes (OR 0.35, 95% CI 0.21 - 0.59 [20 fewer/1 000]) and ipsilateral strokes (OR 0.27, 95% CI 0.19 - 0.39 [30 fewer/1 000]) vs. all BMT. CEA reduced the odds of major strokes and combined stroke and mortality vs. traditional BMT; however, no difference was found between CEA and modern BMT. CAS reduced the odds of peri-operative MI (OR 0.49, 95% CI 0. 26 - 0.91) and CNI (OR 0.07, 95% CI 0.01 - 0.42) vs. CEA.

Conclusion: Modern BMT demonstrates similar reductions in major stroke, combined stroke, and mortality to CEA. The overall risk reductions are low and data were unavailable to assess subgroups which may benefit from intervention. However, BMT carries the potential to reduce the requirement for surgical intervention in patients with ACAS.

Keywords: Best medical treatment; Carotid artery disease; Carotid endarterectomy; Carotid stenting; Meta-analysis.

Publication types

Meta-Analysis
Systematic Review

MeSH terms

Carotid Stenosis* / complications
Carotid Stenosis* / diagnostic imaging
Carotid Stenosis* / surgery
Endarterectomy, Carotid* / adverse effects
Humans
Myocardial Infarction*
Network Meta-Analysis
Risk Assessment
Risk Factors
Stents
Stroke* / epidemiology
Stroke* / etiology
Stroke* / prevention & control
Treatment Outcome