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Percutaneous transluminal angioplasty and stenting for carotid artery stenosisEderle J, Featherstone R, Brown MM
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SummaryPercutaneous transluminal angioplasty and stenting for carotid artery stenosisCarotid stenosis, or narrowing of one of the major arteries which carries blood to the brain, can cause a stroke. The standard treatment is to remove the narrowing by a surgical operation (carotid endarterectomy). The narrowing can also be treated by percutaneous transluminal balloon angioplasty. This involves passing a fine tube (catheter) through the skin (percutaneously) into the arterial system. The catheter has a small balloon at its tip. The catheter is moved through the arterial system until the balloon reaches the point of arterial narrowing in the carotid artery in the neck. The balloon is briefly inflated. This stretches the artery (angioplasty), and reduces the degree of narrowing. More recently a metal scaffolding (stent) is placed inside the artery to prevent it narrowing down again after the catheter is removed. Angioplasty and stenting are called endovascular treatment. This review, which included 12 trials involving 3227 participants, showed that surgery might be better than endovascular treatment in preventing early stroke or death, but there were fewer immediate neurological complications with endovascular treatment than with surgery. However, during follow up, the risk of stroke or death was similar after endarterectomy compared to endovascular treatment. Treated arteries may be more likely to narrow down after endovascular treatment than after carotid endarterectomy. Further randomised trials are needed to see which treatment yields the best chance of long-term freedom from disabling stroke or death.
This is a Cochrane review abstract and plain language summary, prepared and maintained by The Cochrane Collaboration, currently published in The Cochrane Database of Systematic Reviews 2010 Issue 1, Copyright © 2010 The Cochrane Collaboration. Published by John Wiley and Sons, Ltd.. The full text of the review is available in The Cochrane Library (ISSN 1464-780X).
This version first published online:
October 20. 1997 AbstractBackgroundEndovascular treatment by transluminal balloon angioplasty or stent insertion may be a useful alternative to carotid endarterectomy. ObjectivesTo assess the benefits and risks of endovascular treatment compared with carotid endarterectomy or medical therapy. Search strategyWe 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 criteriaWe selected randomised trials of endovascular treatment compared with endarterectomy or medical therapy for carotid artery stenosis. Data collection and analysisOne review author independently applied the inclusion criteria, extracted data and assessed trial quality. Search results were validated by a second review author. Main resultsData 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' conclusionsThe 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. |