Carotid endarterectomy and stenting: A critical analysis of the last randomized controlled trials

INTRODUCTION: The role of carotid artery stenting (CAS) for carotid stenosis is an ongoing matter of debate. Being carotid endarterectomy the gold standard for carotid revascularization, many studies analyzed the real effectiveness of CAS. The aim of the present review was to critically analyze the last randomized controlled trials (RCTs) to compare the different outcomes and the bias of the most important studies. EVIDENCE ACQUISITION: The studies included in the analysis were: Endarterectomy Versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis (EVA3S), Stent-Supported Percutaneous Angioplasty of the Carotid Artery versus Endarterectomy (SPACE), International Carotid Stenting Study (ICSS) and Carotid Revascularization Endarterectomy vs. Stenting Trial (CREST). The trials characteristics and bias were considered. The outcomes analyzed were the death stroke and myocardial infarction (MI) at 30-day. The meta-analysis was performed by random effect model, results reported by odds ratio (OR) and confidence intervals (CI) according the preoperative symptomatic status. EVIDENCE SYNTHESIS: Four RCTs were considered for the analysis with an overall population of 5922 carotid revascularizations. Symptomatic patients were 4741 (80%) and CAS had higher risk of stroke/death OR 1.68 (CI 1.22-3.19), and of death/stroke/MI OR 1.44 (CI: 1.10-1.90). Asymptomatic patients were 1181 (20%) with no significant differences in CEA and CAS groups in terms of death/stroke and death/stroke/MI. CONCLUSIONS: The trials showed a better outcome of CEA in symptomatic patients in terms of death, stroke and MIs. For asymptomatic patients more data are necessary to compare the two carotid revascularization procedures.