Carotid Endarterectomy versus Carotid Artery Stenting: Systematic Review with ☸️SAIMSARA.

DOI: 10.62487/saimsara10028c04

Author: saimsara.com

• Generated: 2025-11-22 10:51:44 CET
• Plan: Premium (expanded craft tokens; source: PubMed)
• Source: PubMed
• Scope: Titles/Abstracts (tiab)
• Keyword Gate: Fuzzy (≥60% of required terms, minimum 2 terms matched in title/abstract)
• Total Abstracts/Papers: 1323
• Downloaded Abstracts/Papers: 1323
• Included original Abstracts/Papers: 710
• Total study participants (naïve ΣN): 3927398

• Bias: The included studies predominantly consist of retrospective cohort studies and mixed designs, with a smaller number of prospective randomized controlled trials (RCTs) and case series. This introduces a potential for selection bias and confounding, particularly in retrospective analyses comparing patient groups who may have been selected for one procedure over another due to underlying risk factors or anatomical considerations. The lack of specification for study type directionality in many entries further limits the ability to infer causality or definitively assess bias in some reported associations.

• Periprocedural Stroke and Mortality Risk: CAS is consistently associated with a higher periprocedural stroke risk (median 2.9% vs 1.5% for CEA) [2, 10, 28, 49, 67, 84, 103, 126, 137, 239, 242, 262, 274, 282, 289, 297, 300, 317, 323, 329, 332, 334, 343, 345, 346, 376, 393, 401, 407, 414, 416, 440, 478, 508, 538, 541, 553, 554, 558, 567, 599, 614, 647, 678, 696], particularly in symptomatic patients [49, 187, 223, 346, 440, 489, 538, 541, 558, 567, 614] and octogenarians [46, 119, 124, 126, 237, 251, 311, 541].
• Silent Cerebral Ischemia and Microembolization: CAS is linked to a significantly higher incidence of new silent cerebral microembolization and DWI-positive lesions post-procedure compared to CEA (e.g., 27.1% vs 13.2% [4], 37% vs 10% [608], 40.3% vs 12.2% [416], 49% vs 25% [431]) [4, 5, 428, 429, 431, 537, 581, 608, 619, 622, 624, 640, 679, 683, 686].
• Restenosis and Reintervention: CAS is associated with a higher risk of restenosis and subsequent reintervention compared to CEA (e.g., 11.0% vs 0% mid-term restenosis [40], RR=1.257 [10], 13.76% vs 5.66% at 2 years [300], 4.6% vs 2.2% instent restenosis [620]), although some studies show similar rates or even lower restenosis for CAS in specific contexts [225, 307, 350, 375, 421, 460, 565, 647, 690].
• Myocardial Infarction and Cardiac Complications: CEA is generally associated with a higher risk of myocardial infarction (MI) compared to CAS (e.g., RR=0.476 for CAS [10], PMI more frequent after CEA [28], 3.4% vs 1.7% MI for CEA-GA vs CAS [392], 1.1% vs 2.3% MI for CAS vs CEA [554], 20% vs 5% major cardiac complications at 5 years [673]) [10, 28, 94, 211, 253, 357, 392, 401, 410, 424, 458, 554, 654, 673, 681].
• Cognitive Function and Ocular Perfusion: Both procedures can improve cognitive function [70, 77, 86, 100, 141, 144, 353, 399, 403, 427, 431], with CEA sometimes showing earlier or superior improvement (e.g., improved visual acuity only after CEA [31], superior ocular perfusion [15, 32], earlier MoCA improvement [244], significant enhancement of MoCA scores [43]). However, one study found CAS superior in cognitive processing speed and executive function at 6 weeks/6 months [411].
• Patient-Specific Factors and Outcomes: Age significantly modifies outcomes, with CAS performance being more sensitive to age [46, 75, 105, 109, 224, 234, 237, 251, 311, 395, 454, 541, 611, 678]. Sex differences exist, with women having higher stroke/death rates after symptomatic CEA or asymptomatic CAS [7, 98, 196, 197, 230, 236, 342, 390, 410, 510, 530, 565]. Comorbidities like type 2 diabetes [3, 217], atrial fibrillation [25, 175, 344, 424], chronic kidney disease [361, 430], and frailty [111, 136, 204] are associated with worse outcomes, with varying impacts across procedures.
• Resource Utilization and Cost-Effectiveness: CEA generally has lower costs than CAS (e.g., marginally lower 1-year cost [26], lower hospital costs [200, 269, 354, 696]), but CAS often has a shorter length of stay [73, 246, 697]. Hospital and operator volume are inversely associated with stroke/death rates for both procedures [62, 139, 154, 170, 232, 278, 337, 366, 600].

• Procedure Selection Based on Risk: CEA appears to offer better short-term stroke protection, particularly for symptomatic patients [440, 489, 538] and octogenarians [119, 124, 126, 237, 251, 311, 541], while CAS may be favored for patients at high cardiac risk due to lower MI rates [10, 28, 392, 554, 673].
• Patient-Specific Considerations: Age and symptomatic status are crucial determinants; CAS performance is more sensitive to age, with increased stroke risk in older patients [46, 224, 454]. Females may face higher risks of stroke/death after symptomatic CEA or asymptomatic CAS [98, 197, 230, 342, 530], warranting careful consideration.
• Monitoring and Follow-up: The higher incidence of silent cerebral infarctions and microemboli after CAS [4, 416, 431, 608, 619, 622, 624, 640, 679, 683] suggests a need for enhanced neurological monitoring, potentially including DWI-MRI, especially post-CAS.
• Restenosis Management: While both procedures carry a risk of restenosis, CAS for post-CEA restenosis may offer comparable or even better outcomes than redo-CEA [307, 375, 421, 565, 690], suggesting a role for staged approaches.
• Center Volume and Expertise: Higher volume centers and experienced operators are consistently associated with better outcomes for both CEA and CAS [62, 139, 154, 170, 232, 278, 337, 366, 600], highlighting the importance of referral to specialized centers.

• Long-term Cognitive Outcomes: Further prospective studies are needed to definitively compare the long-term effects of CEA vs. CAS on various domains of cognitive function, especially beyond 1-2 years [70, 77, 86, 100, 141, 144, 353, 399, 403, 427, 431].
• Optimal Timing for Intervention: More robust RCTs are required to establish the optimal timing for revascularization (CEA or CAS) after acute ischemic stroke, particularly within the first 7 days, where CAS shows a substantially higher risk [249, 346, 362, 478].
• Impact of Novel Devices: Research on the long-term safety and efficacy of newer CAS devices, such as mesh-covered stents and dual-layer stents, is scarce [147, 257, 327, 328], and their comparative performance against CEA needs to be rigorously evaluated.
• Personalized Risk Stratification: Development of more precise risk prediction models incorporating anatomical factors (e.g., plaque vulnerability, lesion length [400, 406, 537]), physiological markers (e.g., NLR, SIRI, BNP [55, 377]), and genetic profiles to identify patients who would unequivocally benefit more from one procedure over the other [83, 273, 302, 306, 358].
• Cost-Effectiveness in Diverse Healthcare Systems: Comprehensive, contemporary cost-effectiveness analyses comparing CEA and CAS across different healthcare systems and patient populations are needed, beyond single-country or short-term assessments [26, 200, 269, 331, 354, 696].

• Study Design Heterogeneity — The variability in study designs, particularly the prevalence of retrospective cohorts, limits the ability to draw definitive causal conclusions.
• Inconsistent Outcome Reporting — Differences in definitions and reporting of key outcomes (e.g., stroke severity, MI, restenosis) across studies hinder direct quantitative comparison and meta-analysis.
• Confounding by Indication — Many studies suffer from confounding by indication, where patient characteristics influence the choice of procedure, making direct comparisons challenging.
• Limited Long-term Data — While some studies provide long-term follow-up, comprehensive long-term comparative data on rare events or subtle outcomes like cognitive decline are still limited.
• Geographic and Practice Variation — The evidence reflects diverse global practices, and outcomes may not be generalizable across all regions or healthcare settings.

• Standardized Outcome Definitions — Implement standardized outcome definitions for stroke, MI, and restenosis in future studies.
• Large Prospective RCTs — Conduct large-scale, prospective randomized controlled trials with long-term follow-up.
• Comparative Effectiveness Research — Focus on comparative effectiveness research in real-world settings with robust adjustment for confounders.
• Biomarker-Guided Decision-Making — Investigate biomarkers to personalize treatment decisions for individual patients.
• Economic Impact Analysis — Perform comprehensive economic analyses across diverse healthcare systems.