Comparative effectiveness and safety of carotid endarterectomy, carotid stenting, and optimal medical therapy across symptomatic and asymptomatic carotid stenosis: An updated network meta-analysis of randomized controlled trials

Authors

• Carolina Hoyos
• Stefan Milutinovic
• Naveed A Delrooz
• Abigail Morse
• Allen Gee
• Cristina Sanina
• Arthur Tarricone
• Karlo A Wiley
• Allison Anker
• Aabha Divya
• Zach Rozenbaum
• Caroline Zahm
• Pedro Cox
• Krishna Allam
• Pedro Villablanca, Henry Ford HealthFollow
• Jamil Borgi
• Sasha Vukelic
• Prakash Krishnan
• Han Feng
• Tiffany W Liu
• Serdar Farhan
• Jose Wiley

Recommended Citation

Hoyos C, Milutinovic S, Delrooz NA, Morse A, Gee A, Sanina C, Tarricone A, Wiley KA, Anker A, Divya A, Rozenbaum Z, Zahm C, Cox P, Allam K, Villablanca P, Borgi J, Vukelic S, Krishnan P, Feng H, Liu TW, Farhan S, Wiley J. Comparative Effectiveness and Safety of Carotid Endarterectomy, Carotid Stenting, and Optimal Medical Therapy across Symptomatic and Asymptomatic Carotid Stenosis: An Updated Network Meta-Analysis of Randomized Controlled Trials. Cardiovasc Revasc Med. 2026.

Document Type

Article

Publication Date

9-9-2026

Publication Title

Cardiovasc Revasc Med

Abstract

BACKGROUND: Carotid stenosis is a major risk factor for ischemic stroke. While carotid endarterectomy (CEA) has historically been the standard of care, carotid artery stenting (CAS) has emerged as a less invasive alternative. However, management remains controversial, particularly in the context of contemporary optimal medical management (OMT).

METHODS: We conducted a systematic review and network meta-analysis of randomized controlled trials (RCT) comparing CAS, CEA, and/or OMT in patients with asymptomatic or symptomatic carotid stenosis. The primary composite outcome was early stroke or death (≤44 days) and ipsilateral stroke during follow-up. Random-effects models were used to estimate pooled relative risks with 95% confidence intervals. Treatment ranking was assessed using surface under the cumulative ranking curve (SUCRA) probabilities.

RESULTS: Nineteen RCTs were included. Most studies compared CEA vs. CAS or CEA vs. OMT, whereas only two RCTs directly compared CAS with OMT. For the primary outcome, CEA was associated with a lower risk compared with CAS in both asymptomatic (RR 0.72, 95% CI 0.54-0.96) and symptomatic patients (RR 0.59, 95% CI 0.43-0.82). In asymptomatic patients, comparisons between CEA and OMT did not reach statistical significance (RR 0.65, 95% CI 0.41-1.04). The CAS vs. OMT comparison was limited by sparse direct evidence (RR 0.91, 95% CI 0.57-1.44). Ranking analysis identified CEA as the highest-ranked treatment strategy across both populations (SUCRA 99.66-100%).

CONCLUSIONS: CEA was associated with a lower risk of the composite outcome compared with CAS in both symptomatic and asymptomatic patients. Although comparisons between revascularization strategies and OMT in asymptomatic patients did not reach statistical significance, point estimates and ranking analyses consistently favored CEA. These findings should be interpreted in the context of limited direct randomized evidence, particularly for CAS versus OMT comparisons.

PubMed ID

42728198

ePublication

ePub ahead of print