[Carotid endarterectomy and carotid stenting. A pilot study of a prospective, randomized and controlled comparison]

ANALYSIS OF SPIN IN VASCULAR SURGERY RANDOMIZED CONTROLLED TRIALS WITH NONSIGNIFICANT OUTCOMES

OBJECTIVES

Spin is the manipulation of language that distorts the interpretation of objective findings. The purpose of this study is to describe the characteristics of spin found in statistically nonsignificant randomized controlled trials (RCT) comparing carotid endarterectomy (CEA) to carotid artery stenting (CAS) for carotid stenosis (CS), and endovascular repair (EVAR) to open repair (OR) for abdominal aortic aneurysms (AAA).

METHODS

A search of MEDLINE, EMBASE, and the Cochrane Controlled Register of Trials was performed in June 2020 for studies published describing AAA or CS. All phase three RCTs with nonsignificant primary outcomes comparing OR to EVAR or CEA to CAS were included. Studies were appraised for the characteristics and severity of spin using a validated tool. Binary logistic regression was performed to assess the association of spin grade to (1) funding source (commercial vs non-commercial) and (2) the publishing journal's impact factor.

RESULTS

Thirty-one of 355 articles captured were included for analysis. Spin was identified in nine abstracts (9/18) and 13 main texts (13/18) of AAA articles and seven abstracts (7/13) and ten main texts (10/13) of CS articles. For both AAA and CS articles, spin was most commonly found in the manuscript discussion section, with the most commonly employed strategy being the interpretation of statistically nonsignificant primary results to show treatment equivalence or rule out adverse treatment effects. Increasing journal impact factor was associated with a statistically significant lower likelihood of spin in the study title or abstract conclusion (βOR = 0.96, 95% CI: 0.94 - 0.98, p < 0.01) while no significant association could be found with funding source (βOR = 1.33, 95% CI: 0.30-5.92, p = 0.71).

CONCLUSIONS

A large proportion of statistically nonsignificant RCTs contain interpretations that are inconsistent with their results. These findings should prompt authors and readers to appraise study findings independently and to limit the use of spin in study interpretations.

Methodological quality and redundancy of systematic reviews that compare endarterectomy versus stenting for carotid stenosis

A review of systematic reviews (SRs) and a critical appraisal study was conducted at Escola Paulista de Medicina, Universidade Federal de São Paulo (Unifesp). The objectives of this review are (1) to identify all published SRs comparing the effectiveness and safety of carotid endarterectomy (CEA) versus carotid artery stenting (CAS) for carotid artery stenosis, (2) to assess their methodological quality and (3) to compare the primary studies contained in each SR. We included 17 SRs published between 2005 and 2017. None of the SRs fulfilled all items of AMSTAR-2. The overall confidence in the results was graded as critically low for 16 SRs (94%) and low for 1 SR (6%). Five items were judged inadequate in all SRs: reference to a published protocol, explanation to the selection of study design, comprehensive search of the literature, methods for statistical combination of findings and consideration of the risk of bias on the results of meta-analysis. In total, 15 randomised clinical trials (RCTs) were included at least in one SR. The number of included RCTs in each SR was inconsistent (4 to 15) and was not related to the year of publication of the SR. Our study found redundant and low methodological quality SR comparing CAS versus CEA for carotid stenosis.

Carotid artery stenting versus endarterectomy for treatment of carotid artery stenosis

BACKGROUND

Carotid artery stenting is an alternative to carotid endarterectomy for the treatment of atherosclerotic carotid artery stenosis. This review updates a previous version first published in 1997 and subsequently updated in 2004, 2007, and 2012.

OBJECTIVES

To assess the benefits and risks of stenting compared with endarterectomy in people with symptomatic or asymptomatic carotid stenosis.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (last searched August 2018) and the following databases: CENTRAL, MEDLINE, Embase, and Science Citation Index to August 2018. We also searched ongoing trials registers (August 2018) and reference lists, and contacted researchers in the field.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing stenting with endarterectomy for symptomatic or asymptomatic atherosclerotic carotid stenosis. In addition, we included RCTs comparing carotid artery stenting with medical therapy alone.

DATA COLLECTION AND ANALYSIS

One review author selected trials for inclusion, assessed trial quality and risk of bias, and extracted data. A second review author independently validated trial selection and a third review author independently validated data extraction. We calculated treatment effects as odds ratios (OR) and 95% confidence intervals (CI), with endarterectomy as the reference group. We quantified heterogeneity using the I² statistic and used GRADE to assess the overall certainty of evidence.

MAIN RESULTS

We included 22 trials involving 9753 participants. In participants with symptomatic carotid stenosis, compared with endarterectomy stenting was associated with a higher risk of periprocedural death or stroke (the primary safety outcome; OR 1.70, 95% CI 1.31 to 2.19; P < 0.0001, I² = 5%; 10 trials, 5396 participants; high-certainty evidence); and periprocedural death, stroke, or myocardial infarction (OR 1.43, 95% CI 1.14 to 1.80; P = 0.002, I² = 0%; 6 trials, 4861 participants; high-certainty evidence). The OR for the primary safety outcome was 1.11 (95% CI 0.74 to 1.64) in participants under 70 years old and 2.23 (95% CI 1.61 to 3.08) in participants 70 years old or more (interaction P = 0.007). There was a non-significant increase in periprocedural death or major or disabling stroke with stenting (OR 1.36, 95% CI 0.97 to 1.91; P = 0.08, I² = 0%; 7 trials, 4983 participants; high-certainty evidence). Compared with endarterectomy, stenting was associated with lower risks of myocardial infarction (OR 0.47, 95% CI 0.24 to 0.94; P = 0.03, I² = 0%), cranial nerve palsy (OR 0.09, 95% CI 0.06 to 0.16; P < 0.00001, I² = 0%), and access site haematoma (OR 0.32, 95% CI 0.15 to 0.68; P = 0.003, I² = 27%). The combination of periprocedural death or stroke or ipsilateral stroke during follow-up (the primary combined safety and efficacy outcome) favoured endarterectomy (OR 1.51, 95% CI 1.24 to 1.85; P < 0.0001, I² = 0%; 8 trials, 5080 participants; high-certainty evidence). The rate of ipsilateral stroke after the periprocedural period did not differ between treatments (OR 1.05, 95% CI 0.75 to 1.47; P = 0.77, I² = 0%). In participants with asymptomatic carotid stenosis, there was a non-significant increase in periprocedural death or stroke with stenting compared with endarterectomy (OR 1.72, 95% CI 1.00 to 2.97; P = 0.05, I² = 0%; 7 trials, 3378 participants; moderate-certainty evidence). The risk of periprocedural death or stroke or ipsilateral stroke during follow-up did not differ significantly between treatments (OR 1.27, 95% CI 0.87 to 1.84; P = 0.22, I² = 0%; 6 trials, 3315 participants; moderate-certainty evidence). Moderate or higher carotid artery restenosis (50% or greater) or occlusion during follow-up was more common after stenting (OR 2.00, 95% CI 1.12 to 3.60; P = 0.02, I² = 44%), but the difference in risk of severe restenosis was not significant (70% or greater; OR 1.26, 95% CI 0.79 to 2.00; P = 0.33, I² = 58%; low-certainty evidence).

AUTHORS' CONCLUSIONS

Stenting for symptomatic carotid stenosis is associated with a higher risk of periprocedural stroke or death than endarterectomy. This extra risk is mostly attributed to an increase in minor, non-disabling strokes occurring in people older than 70 years. Beyond the periprocedural period, carotid stenting is as effective in preventing recurrent stroke as endarterectomy. However, combining procedural safety and long-term efficacy in preventing recurrent stroke still favours endarterectomy. In people with asymptomatic carotid stenosis, there may be a small increase in the risk of periprocedural stroke or death with stenting compared with endarterectomy. However, CIs of treatment effects were wide and further data from randomised trials in people with asymptomatic stenosis are needed.

Percutaneous transluminal balloon angioplasty and stenting for carotid artery stenosis

BACKGROUND

Endovascular treatment by transluminal balloon angioplasty or stent insertion may be a useful alternative to carotid endarterectomy for the treatment of atherosclerotic carotid artery stenosis. This review updates a previous version first published in 1997 and subsequently updated in 2004 and 2007.

OBJECTIVES

To assess the benefits and risks of endovascular treatment compared with carotid endarterectomy or medical therapy in patients with symptomatic or asymptomatic carotid stenosis.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (last searched January 2012) and the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 4), MEDLINE (1950 to January 2011), EMBASE (1980 to January 2011) and Science Citation Index (1945 to January 2011). We also searched ongoing trials registers (January 2011) and reference lists and contacted researchers in the field.

SELECTION CRITERIA

Randomised trials comparing endovascular treatment (including balloon angioplasty or stenting) with endarterectomy or medical therapy for symptomatic or asymptomatic atherosclerotic carotid stenosis.

DATA COLLECTION AND ANALYSIS

One review author selected trials for inclusion, assessed trial quality and extracted data. A second review author independently validated trial selection and a third review author independently validated data extraction. We calculated treatment effects as odds ratios (OR) and 95% confidence intervals (CI), with endovascular treatment as the reference group. We quantified heterogeneity using the I(2) statistic.

MAIN RESULTS

We included 16 trials involving 7572 patients. In patients with symptomatic carotid stenosis at standard surgical risk, endovascular treatment was associated with a higher risk of the following outcome measures occurring between randomisation and 30 days after treatment than endarterectomy: death or any stroke (the primary safety outcome) (OR 1.72, 95% CI 1.29 to 2.31, P = 0.0003; I(2) = 27%), death or any stroke or myocardial infarction (OR 1.44, 95% CI 1.15 to 1.80, P = 0.002; I(2) = 7%), and any stroke (OR 1.81, 95% CI 1.40 to 2.34, P < 0.00001;I(2) = 12%). The OR for the primary safety outcome was 1.16 (95% CI 0.80 to 1.67) in patients < 70 years old and 2.20 (95% CI 1.47 to 3.29) in patients ≥ 70 years old (interaction P = 0.02).The rate of death or major or disabling stroke did not differ significantly between treatments (OR 1.28, 95% CI 0.93 to 1.77, P = 0.13; I(2) = 0%). Endovascular treatment was associated with lower risks of myocardial infarction (OR 0.44, 95% CI 0.23 to 0.87, P = 0.02; I(2) = 0%), cranial nerve palsy (OR 0.08, 95% CI 0.05 to 0.14, P < 0.00001; I(2) = 0%) and access site haematomas (OR 0.37, 95% CI 0.18 to 0.77, P = 0.008; I(2) = 27%).The combination of death or any stroke up to 30 days after treatment or ipsilateral stroke during follow-up (the primary combined safety and efficacy outcome) favoured endarterectomy (OR 1.39, 95% CI 1.10 to 1.75, P = 0.005; I(2) = 0%), but the rate of ipsilateral stroke after the peri-procedural period did not differ between treatments (OR 0.93, 95% CI 0.60 to 1.45, P = 0.76; I(2) = 0%).Restenosis during follow-up was more common in patients receiving endovascular treatment than in patients assigned surgery (OR 2.41, 95% CI 1.28 to 4.53, P = 0.007; I(2) = 55%). In patients with asymptomatic carotid stenosis, treatment effects on the primary safety (OR 1.71, 95% CI 0.78 to 3.76, P = 0.18; I(2) = 0%) and combined safety and efficacy outcomes (OR 1.75, 95% CI 0.92 to 3.33, P = 0.09; I(2) = 0%) were similar to symptomatic patients, but differences between treatments were not statistically significant. Among patients not suitable for surgery, the rate of death or any stroke between randomisation and end of follow-up did not differ significantly between endovascular treatment and medical care (OR 0.22, 95% CI 0.01 to 7.92, P = 0.41; I(2)= 79%).

AUTHORS' CONCLUSIONS

Endovascular treatment is associated with an increased risk of peri-procedural stroke or death compared with endarterectomy. However, this excess risk appears to be limited to older patients. The longer term efficacy of endovascular treatment and the risk of restenosis are unclear and require further follow-up of existing trials. Further trials are needed to determine the optimal treatment for asymptomatic carotid stenosis.

Carotid endarterectomy is superior to carotid angioplasty and stenting for perioperative and long-term results

OBJECTIVE

Carotid angioplasty and stenting (CAS) has challenged carotid endarterectomy (CEA) as the therapy of choice for carotid disease. This meta-analysis aims at summarizing the most current body of evidence.

METHODS

All prospective, controlled clinical trials comparing CEA versus CAS were included. The outcome measures of interest were relative risk (RR) of 30-day stroke, 30-day stroke/death, long-term risk of stroke, and risk of restenosis.

RESULTS

The RR of 30-day stroke for CAS was 1.6 times that of CEA (RR 1.6; 95%CI 1.2-2.0, P = .001). The 30-day RR of stroke/death was 1.5 times higher for CAS (RR 1.5; 95%CI 1.1-2.1, P = .008). There was a higher risk of long-term stroke (RR 1.2; 95%CI 1.0-1.5, P = .043). The risk of restenosis was twice for CAS (RR 1.8; 95%CI 1.1-3.1, P = .04).

CONCLUSION

The 30-day RR of stroke, stroke/death, long-term risk of stroke, and risk of restenosis are consistently higher for carotid artery stenting (CAS).

Carotid Artery Stenting Versus Carotid Endarterectomy

Background and Purpose—

The comparison between carotid endarterectomy and carotid artery stenting (CAS) remains a debated field, especially in the context of long-term outcomes.

Methods—

Concerning the short-term (30-day) analysis, the numbers of outcomes per arm were abstracted, whereas outcomes per arm and hazard ratios were abstracted for long-term (≥1-year) results.

Results—

Thirteen randomized trials (3723 carotid endarterectomy and 3754 CAS patients) were eligible. Regarding short-term outcomes, CAS was associated with elevated risk for stroke and “death or stroke.” CAS also exhibited a marginal trend toward higher death and “death or disabling stroke” rates. Carotid endarterectomy presented with higher rates of myocardial infarction and cranial nerve injury. Concerning long-term outcomes, CAS was associated with higher rates of stroke (pooled OR, 1.37; 95% CI, 1.13 to 1.65) and “death or stroke” (pooled OR, 1.25; 95% CI, 1.06 to 1.48). These findings were replicated at the level of pooled hazard ratios and marginally regarding secondary preventive efficacy. The difference in long-term stroke rates was particularly sizeable in patients >68 years, but little difference in rates was observed in those <68 years. No statistically significant heterogeneity became evident. Metaregression did not reveal any significant modifying effect mediated by symptomatic/asymptomatic status, distal protection, early termination of trials, area of study origin, or CAS learning curve.

Conclusions—

This meta-analysis points to the significantly less frequent stroke events after carotid endarterectomy at the long-term context. The outcomes of carotid endarterectomy seem superior to CAS, but there may be subgroups, particularly younger patients, in whom the results seem equivalent.

Does sex matter? Thirty-day stroke and death rates after carotid artery stenting in women versus men: results from the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) lead-in phase

BACKGROUND AND PURPOSE

Several carotid endarterectomy randomized, controlled trials and series have reported higher perioperative stroke and death rates for women compared with men. The potential for this same relationship with carotid artery stenting was examined in the lead-in phase of the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST).

METHODS

CREST compares efficacy of carotid endarterectomy and carotid artery stenting in preventing stroke, myocardial infarction, and death in the periprocedural period and ipsilateral stroke over the follow-up period. CREST included a "lead-in" phase of symptomatic (>or=50% stenosis) and asymptomatic (>or=70% stenosis) patients. Patients were examined by a neurologist preprocedure, at 24 hours, and at 30 days. Review of stroke and death was by an independent events committee. The association of sex with periprocedural stroke and death was examined in 1564 patients undergoing carotid artery stenting (26.5% symptomatic).

RESULTS

Women comprised 37% of the lead-in cohort and did not differ from men by age, symptomatic status, or characteristics of the internal carotid artery. The 30-day stroke and death rate for women was 4.5% (26 of 579; 95% CI, 3.0% to 6.5%) compared with 4.2% (41 of 985; 95% CI, 3.0% to 5.6%) for men. The difference in stroke and death rate was not significant nor were there any significant differences by sex after adjustment for age, arterial characteristics, or cardiovascular risk factors.

CONCLUSIONS

These results do not provide evidence that women have a higher carotid artery stenting stroke and death rate compared with men. The potential differential periprocedural risk by sex will be prospectively addressed in the randomized phase of CREST.

Percutaneous transluminal angioplasty and stenting for carotid artery stenosis

BACKGROUND

Endovascular treatment by transluminal balloon angioplasty or stent insertion may be a useful alternative to carotid endarterectomy.

OBJECTIVES

To assess the benefits and risks of endovascular treatment compared with carotid endarterectomy or medical therapy.

SEARCH STRATEGY

We searched the Cochrane Stroke Group trials register (last searched 14 March 2007) and the following bibliographic databases: Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 1, 2007), MEDLINE (1950 to March 2007), EMBASE (1980 to March 2007) and Science Citation Index (1945 to March 2007). We also contacted researchers in the field.

SELECTION CRITERIA

We selected randomised trials of endovascular treatment compared with endarterectomy or medical therapy for carotid artery stenosis.

DATA COLLECTION AND ANALYSIS

One review author independently applied the inclusion criteria, extracted data and assessed trial quality. Search results were validated by a second review author.

MAIN RESULTS

Data were available from 12 trials (3227 patients) but not all contributed to each analysis. The primary outcome comparison of any stroke or death within 30 days of treatment favoured surgery (odds ratio (OR) 1.39, P = 0.02, not significant (NS) in the random-effects model). The following outcome comparisons favoured endovascular treatment over surgery: cranial neuropathy (OR 0.07, P < 0.01); 30 day neurological complication or death (OR 0.62, P = 0.004, NS in the random-effects model, with significant heterogeneity). The following outcome comparisons showed little difference between endovascular treatment and surgery: 30 day stroke, myocardial infarction or death (OR 1.11, P = 0.57 with significant heterogeneity); stroke during long-term follow up (OR 1.00). Comparison between endovascular treatment with or without protection device showed no significant difference in 30 day stroke or death (OR 0.77, P = 0.42 with significant heterogeneity). Analysis of stroke or death within 30 days of the procedure in asymptomatic carotid stenosis showed no difference (OR 1.06, P = 0.96). In patients not suitable for surgery, there was no significant difference in 30 day stroke or death (OR 0.39, P = 0.09 with significant heterogeneity).

AUTHORS' CONCLUSIONS

The data are difficult to interpret because the trials are heterogeneous (different patients, endovascular procedures, and duration of follow up) and five trials were stopped early, perhaps leading to an over-estimate of the risks of endovascular treatment. The pattern of effects on different outcomes does not support a change in clinical practice away from recommending carotid endarterectomy as the treatment of choice for suitable carotid artery stenosis.

Carotid Angioplasty with or without Stent Placement versus Carotid Endarterectomy for Treatment of Carotid Stenosis: A Meta-analysis

OBJECTIVE:

Carotid angioplasty with or without stent placement (CAS) has been proposed as an alternative method to carotid endarterectomy (CEA) for treatment of carotid stenosis. Small randomized trials have evaluated the comparative efficacy of both methods; however, definitive evidence is lacking.

METHODS:

A search was made for randomized clinical trials comparing CAS and CEA for treatment of carotid stenosis. A literature search of MEDLINE, PubMed, and Cochrane databases was supplemented by a review of bibliographies of relevant articles and personal files. A meta-analysis was performed using a random effects model because significant heterogeneity was observed. Outcomes compared included 1-month composite rates of stroke or death, all strokes, disabling strokes, myocardial infarction, cranial nerve injury, and major bleeding and 1-year rates of both minor and major ipsilateral strokes.

RESULTS:

We analyzed five randomized trials totaling 1154 patients (577 randomized to CEA and 577 randomized to CAS). The composite end point of 1-month stroke or death rate was not different between patients treated with CAS compared with those treated with CEA (relative risk [RR], 1.3; 95% confidence interval [CI], 0.6–2.8; P = 0.5). The 1-month stroke rate (831 patients analyzed: RR, 1.3; 95% CI, 0.4–3.6; P = 0.7) and disabling stroke rate (831 patients analyzed: RR, 0.9; 95% CI, 0.2–3.5; P = 0.9) was similar for CAS and CEA. The 1-month rates of myocardial infarction (814 patients analyzed: RR, 0.3; 95% CI, 0.1–0.9) and cranial nerve injury (918 patients analyzed: RR, 0.05; 95% CI, 0.01–0.3) were significantly lower for CAS. No significant differences were observed in 1-year rates of ipsilateral stroke (814 patients analyzed: RR, 0.8; 95% CI, 0.5–1.2; P = 0.2).

CONCLUSION:

The 30-day stroke and death rates associated with CAS and CEA were not significantly different. Lower rates of myocardial infarction and cranial nerve injury were observed with CAS compared with CEA.

In Vivo Evaluation of the Carotid Wallstent on Three-dimensional Contrast Material–enhanced MR Angiography: Influence of Artifacts on the Visibility of Stent Lumina

PURPOSE

Contrast material-enhanced magnetic resonance (MR) angiography is increasingly used in postinterventional imaging after implantation of endovascular stents. The main limitations are stent-related artifacts compromising the visibility of the stent lumen. The aim of this in vivo study is the evaluation of contrast-enhanced MR angiography imaging characteristics of the carotid Wallstent.

MATERIALS AND METHODS

The carotid arteries of 29 patients were examined with contrast-enhanced MR angiography 3-6 days and/or 7-23 months after implantation of a carotid Wallstent into the internal carotid artery. Images were evaluated with regard to the diameter and signal intensity (SI) of the visible stent lumen. Digital subtraction angiography (DSA) was used as the standard of reference.

RESULTS

Stent-related artifacts on contrast-enhanced MR angiography caused an artificial lumen narrowing and a reduction of the SI within the stent. Artifacts were pronounced on imaging 3-6 days after stent implantation, but 68% of stents imaged 7-23 months after stent implantation presented with a significantly decreased artificial signal reduction and an improved visibility of the stent lumen.

CONCLUSIONS

The results of this study indicate that a reliable evaluation of the stent lumen is limited as a result of an artificial decrease of the SI inside the stent. However, in follow-up examinations 7-23 months after stent implantation, visibility of the stent lumen was improved and diagnostic reliability of contrast-enhanced MR angiography was markedly increased. A probable explanation for this phenomenon might be the formation of a neointimal layer covering the stent struts and thereby reducing stent-related artifacts.

Behandlung der arteriosklerotischen Karotisstenose: ein �berblick

Endarterectomy for extracranial carotid stenosis has proven to be the method of choice for symptomatic patients suffering from ischemia (NASCET, ECST). The effectivity of the operation for asymptomatic stenosis seems to be likely since the publication of the first results of the ACST trial. The safety and efficiency of carotid stenting has not been proven so far and has to be evaluated in randomized trials comparing surgery and endovascular treatment. We provide an overview of the current trials and try to define the role of carotid stenting.

Endovascular treatment of cerebrovascular diseases and intracranial neoplasms

Cerebrovascular diseases are an important cause of morbidity and mortality worldwide. Endovascular treatment has emerged as a minimally invasive approach to treat cerebrovascular diseases and possibly intracranial neoplasms. Practice patterns for selection of patients for endovascular treatment are continuously being modified on the basis of new information derived from clinical studies. In this review, I discuss the various endovascular treatments for diseases such as ischaemic stroke, carotid and intracranial stenosis, intracranial aneurysms, arteriovenous malformations, malignant gliomas, and meningiomas.

[Evaluation of stent-protected angioplasty for theray of symptomatic stenoses of the carotid artery. SPACE and other randomized trials]

During recent years, stent-protected angioplasty of the carotid artery (SPAC) has become an alternative to endartectomy (CEA) in many centers. Despite many case reports, case series, and open records, it has not been proven that these therapeutical regimens are comparable regarding complication rates and long-term outcome. Until now, only three randomized trials were published on this theme, two of them only as abstracts. This is not sufficient for answering the question of whether SPAC is a good alternative to CEA. At present, four major, randomized, multicenter trials are being run (EVA3S in France, CREST in the US, ICSS in Great Britain and several other countries, and SPACE in Germany and Austria). About 7,300 patients will be included in these trials. At present, 24 centers are participating in the SPACE trial, recruiting about 350 patients. It has been prospectively agreed that EVA-3S, ICSS, and SPACE will combine their results after completion of initial randomization and follow-up to conduct a combined European meta-analysis of the data. Three to 5 years are needed until these trials' final results will be published. Until then, stent-protected angioplasty should be done only under the consideration that it has not been scientifically evaluated.

Early outcome of carotid angioplasty and stenting with and without cerebral protection devices: a systematic review of the literature

BACKGROUND

Carotid angioplasty and stenting (CAS) is increasingly being used for treatment of symptomatic and asymptomatic carotid artery disease (CAD). To evaluate the efficacy of cerebral protection devices in preventing thromboembolic complications during CAS, we conducted a systematic review of studies reporting on the incidence of minor stroke, major stroke, or death within 30 days after CAS.

SUMMARY OF REVIEW

We searched for studies published between January 1990 and June 2002 by means of a PubMed search and a cumulative review of reference lists of all relevant publications. In 2357 patients a total of 2537 CAS procedures had been performed without protection devices, and in 839 patients 896 CAS procedures had been performed with protection devices. Both groups were similar with respect to age, sex distribution, cerebrovascular risk factors, and indications for CAS. In many studies the periprocedural complication rates had not been presented separately for patients with symptomatic and asymptomatic CAD. The combined stroke and death rate within 30 days in both symptomatic and asymptomatic patients was 1.8% in patients treated with cerebral protection devices compared with 5.5% in patients treated without cerebral protection devices (chi2=19.7, P<0.001). This effect was mainly due to a decrease in the occurrence of minor strokes (3.7% without cerebral protection versus 0.5% with cerebral protection; chi2=22.4, P<0.001) and major strokes (1.1% without cerebral protection versus 0.3% with cerebral protection; chi2=4.3, P<0.05), whereas death rates were almost identical (approximately 0.8%; chi2=0.3, P=0.6).

CONCLUSIONS

On the basis of this early analysis of single-center studies, the use of cerebral protection devices appears to reduce thromboembolic complications during CAS. These technical aspects should be taken into account before the initiation of further randomized trials comparing CAS with carotid endarterectomy.