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Systematic Review and Meta-Analysis of Carotid Artery Stenting Versus Endarterectomy for Carotid Stenosis: A Chronological and Worldwide Study.

Zhang L, Zhao Z, Ouyang Y, Bao J, Lu Q, Feng R, Zhou J, Jing Z - Medicine (Baltimore) (2015)

Bottom Line: This systematic review, compared with those of other meta-analyses, included all available comparative studies and analyzed them at 5-year intervals, in different continents, and under different study designs.Current evidence suggests that the efficacy of CEA is superior to CAS for freedom from stroke/death within 30 d, especially from 2006 to 2015, in North America and Europe.Meanwhile, the superiority was also observed for restenosis at 1-year, transient ischemic attack within 30 d, and stroke/death at 4- and 10-year follow-ups.

View Article: PubMed Central - PubMed

Affiliation: From the Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China (LZ, ZZ, YO, JB, QL, RF, ZJ); and Department of Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China (JZ).

ABSTRACT
There are disparities among the results of meta-analyses under different circumstances of carotid artery stenting (CAS) versus endarterectomy (CEA) for carotid stenosis. This study aimed to assess the efficacies of CAS and CEA for carotid stenosis at 5-year intervals and worldwide.Comparative studies simultaneously reporting CAS and CEA for carotid stenosis with at least 10 patients in each group were identified by searching PubMed and Embase in accordance with preferred reporting items for systematic reviews and meta-analyses guidelines, and by reviewing the reference lists of retrieved articles.The studies were stratified into different subgroups according to the publication year, location in which the study was mainly performed, and randomized and nonrandomized study designs.Thirty-five comparative studies encompassing 27,525 patients were identified. The risk ratios (RRs) of stroke/death when CAS was compared with CEA within 30 d of treatment were 1.51 (95% CI 1.32-1.74, P < 0.001) for overall, 1.50 (95% CI 1.14-1.98, P = 0.004) from 2011 to 2015, 1.61 (95% CI 1.35-1.91, P < 0.001) from 2006 to 2010, 1.59 (95% CI 1.27-1.99, P < 0.001) in North America, 1.50 (95% CI 1.24-1.81, P < 0.001) in Europe, 1.63 (95% CI 1.31-2.02, P < 0.001) for randomized, and 1.44 (95% CI 1.20-1.73, P < 0.001) for nonrandomized comparative studies. CEA decreased the risks of transient ischemic attack at 30 d (RR: 2.07, 95% CI 1.50-2.85, P < 0.001) and restenosis at 1-year (RR: 1.97, 95% CI 1.28-3.05, P = 0.002). Data from follow-up showed that the RRs of stroke/death were 0.74 (95% CI 0.55-0.99, P = 0.04) at 1 year, 1.24 (95% CI 1.04-1.46, P = 0.01) at 4 year, and 2.27 (95% CI 1.39-3.71, P = 0.001) at 10 year. This systematic review, compared with those of other meta-analyses, included all available comparative studies and analyzed them at 5-year intervals, in different continents, and under different study designs. Current evidence suggests that the efficacy of CEA is superior to CAS for freedom from stroke/death within 30 d, especially from 2006 to 2015, in North America and Europe. Meanwhile, the superiority was also observed for restenosis at 1-year, transient ischemic attack within 30 d, and stroke/death at 4- and 10-year follow-ups.

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Meta-analysis of the stroke/death rate within 30 d from randomized and nonrandomized comparative studies. (A) The efficacy of CEA for freedom from stroke/death within 30 d was superior to that of CAS in randomized and nonrandomized comparative studies. (B) The likelihood of publication bias was low. CaRESS = carotid revascularization using endarterectomy or stenting systems, CAS = carotid artery stenting, CEA = carotid endarterectomy, CI = confidence interval(s), CREST = carotid revascularization endarterectomy versus stenting trial, EVA-3S = endarterectomy versus angioplasty in patients with symptomatic severe carotid stenosis, ICSS = international carotid stenting study, RCTs = randomized comparative studies, SAPPHIRE = stenting and angioplasty with protection in patients at high risk for endarterectomy, SPACE = stent-supported percutaneous angioplasty of the carotid artery versus endarterectomy.
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Figure 5: Meta-analysis of the stroke/death rate within 30 d from randomized and nonrandomized comparative studies. (A) The efficacy of CEA for freedom from stroke/death within 30 d was superior to that of CAS in randomized and nonrandomized comparative studies. (B) The likelihood of publication bias was low. CaRESS = carotid revascularization using endarterectomy or stenting systems, CAS = carotid artery stenting, CEA = carotid endarterectomy, CI = confidence interval(s), CREST = carotid revascularization endarterectomy versus stenting trial, EVA-3S = endarterectomy versus angioplasty in patients with symptomatic severe carotid stenosis, ICSS = international carotid stenting study, RCTs = randomized comparative studies, SAPPHIRE = stenting and angioplasty with protection in patients at high risk for endarterectomy, SPACE = stent-supported percutaneous angioplasty of the carotid artery versus endarterectomy.

Mentions: The risk ratios of restenosis at follow-up were 1.97 (95% CI 1.28–3.05, P = 0.002) after 1 year and 1.45 (95% CI 0.62–3.41, P = 0.39) after 2 year. Heterogeneity was 0% and 88%, respectively, after 1 and 2 year. The forest plot showed that the efficacy of CEA was superior to that of CAS at the 1-year follow-up point. The incidence rates for CAS and CEA were 7.4% and 3.6% at 1 year, and 6.6% and 5.0% at 2-year follow-up, respectively (Figure 5A). The funnel plot showed no significant evidence of asymmetry (see Figure S2A, Supplemental Content, which demonstrates the funnel plot for publication bias assessment of restenosis rate).


Systematic Review and Meta-Analysis of Carotid Artery Stenting Versus Endarterectomy for Carotid Stenosis: A Chronological and Worldwide Study.

Zhang L, Zhao Z, Ouyang Y, Bao J, Lu Q, Feng R, Zhou J, Jing Z - Medicine (Baltimore) (2015)

Meta-analysis of the stroke/death rate within 30 d from randomized and nonrandomized comparative studies. (A) The efficacy of CEA for freedom from stroke/death within 30 d was superior to that of CAS in randomized and nonrandomized comparative studies. (B) The likelihood of publication bias was low. CaRESS = carotid revascularization using endarterectomy or stenting systems, CAS = carotid artery stenting, CEA = carotid endarterectomy, CI = confidence interval(s), CREST = carotid revascularization endarterectomy versus stenting trial, EVA-3S = endarterectomy versus angioplasty in patients with symptomatic severe carotid stenosis, ICSS = international carotid stenting study, RCTs = randomized comparative studies, SAPPHIRE = stenting and angioplasty with protection in patients at high risk for endarterectomy, SPACE = stent-supported percutaneous angioplasty of the carotid artery versus endarterectomy.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4504641&req=5

Figure 5: Meta-analysis of the stroke/death rate within 30 d from randomized and nonrandomized comparative studies. (A) The efficacy of CEA for freedom from stroke/death within 30 d was superior to that of CAS in randomized and nonrandomized comparative studies. (B) The likelihood of publication bias was low. CaRESS = carotid revascularization using endarterectomy or stenting systems, CAS = carotid artery stenting, CEA = carotid endarterectomy, CI = confidence interval(s), CREST = carotid revascularization endarterectomy versus stenting trial, EVA-3S = endarterectomy versus angioplasty in patients with symptomatic severe carotid stenosis, ICSS = international carotid stenting study, RCTs = randomized comparative studies, SAPPHIRE = stenting and angioplasty with protection in patients at high risk for endarterectomy, SPACE = stent-supported percutaneous angioplasty of the carotid artery versus endarterectomy.
Mentions: The risk ratios of restenosis at follow-up were 1.97 (95% CI 1.28–3.05, P = 0.002) after 1 year and 1.45 (95% CI 0.62–3.41, P = 0.39) after 2 year. Heterogeneity was 0% and 88%, respectively, after 1 and 2 year. The forest plot showed that the efficacy of CEA was superior to that of CAS at the 1-year follow-up point. The incidence rates for CAS and CEA were 7.4% and 3.6% at 1 year, and 6.6% and 5.0% at 2-year follow-up, respectively (Figure 5A). The funnel plot showed no significant evidence of asymmetry (see Figure S2A, Supplemental Content, which demonstrates the funnel plot for publication bias assessment of restenosis rate).

Bottom Line: This systematic review, compared with those of other meta-analyses, included all available comparative studies and analyzed them at 5-year intervals, in different continents, and under different study designs.Current evidence suggests that the efficacy of CEA is superior to CAS for freedom from stroke/death within 30 d, especially from 2006 to 2015, in North America and Europe.Meanwhile, the superiority was also observed for restenosis at 1-year, transient ischemic attack within 30 d, and stroke/death at 4- and 10-year follow-ups.

View Article: PubMed Central - PubMed

Affiliation: From the Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China (LZ, ZZ, YO, JB, QL, RF, ZJ); and Department of Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China (JZ).

ABSTRACT
There are disparities among the results of meta-analyses under different circumstances of carotid artery stenting (CAS) versus endarterectomy (CEA) for carotid stenosis. This study aimed to assess the efficacies of CAS and CEA for carotid stenosis at 5-year intervals and worldwide.Comparative studies simultaneously reporting CAS and CEA for carotid stenosis with at least 10 patients in each group were identified by searching PubMed and Embase in accordance with preferred reporting items for systematic reviews and meta-analyses guidelines, and by reviewing the reference lists of retrieved articles.The studies were stratified into different subgroups according to the publication year, location in which the study was mainly performed, and randomized and nonrandomized study designs.Thirty-five comparative studies encompassing 27,525 patients were identified. The risk ratios (RRs) of stroke/death when CAS was compared with CEA within 30 d of treatment were 1.51 (95% CI 1.32-1.74, P < 0.001) for overall, 1.50 (95% CI 1.14-1.98, P = 0.004) from 2011 to 2015, 1.61 (95% CI 1.35-1.91, P < 0.001) from 2006 to 2010, 1.59 (95% CI 1.27-1.99, P < 0.001) in North America, 1.50 (95% CI 1.24-1.81, P < 0.001) in Europe, 1.63 (95% CI 1.31-2.02, P < 0.001) for randomized, and 1.44 (95% CI 1.20-1.73, P < 0.001) for nonrandomized comparative studies. CEA decreased the risks of transient ischemic attack at 30 d (RR: 2.07, 95% CI 1.50-2.85, P < 0.001) and restenosis at 1-year (RR: 1.97, 95% CI 1.28-3.05, P = 0.002). Data from follow-up showed that the RRs of stroke/death were 0.74 (95% CI 0.55-0.99, P = 0.04) at 1 year, 1.24 (95% CI 1.04-1.46, P = 0.01) at 4 year, and 2.27 (95% CI 1.39-3.71, P = 0.001) at 10 year. This systematic review, compared with those of other meta-analyses, included all available comparative studies and analyzed them at 5-year intervals, in different continents, and under different study designs. Current evidence suggests that the efficacy of CEA is superior to CAS for freedom from stroke/death within 30 d, especially from 2006 to 2015, in North America and Europe. Meanwhile, the superiority was also observed for restenosis at 1-year, transient ischemic attack within 30 d, and stroke/death at 4- and 10-year follow-ups.

Show MeSH
Related in: MedlinePlus