Carotid Revascularization in Older Adults: A Systematic Review and Meta-Analysis

Background Results from studies comparing carotid artery endarterectomy (CEA) with carotid artery stenting (CAS) in the elderly population are variable in the literature. The objective of this study was to investigate whether CEA or CAS is associated with a better safety profile in older adults (>80 years of age) for treatment of symptomatic and asymptomatic stenosis. Methods A random-effects meta-analysis was performed, and the I 2 statistic was used to assess heterogeneity according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Subgroup analyses were performed as needed. Results Nine studies comprising 5955 patients were included in this meta-analysis. No differences were identified in terms of 30-day stroke (CEA: 5.8% [n = 257/4415]; CAS: 10.5% [n = 81/767]; odds ratio [OR], 0.57; 95% confidence interval [CI], 0.30–1.08; I 2  = 26.1%), myocardial infarction (MI) (CEA: 1.1% [n = 4/357]; CAS: 0.5% [n = 2/355]; OR, 1.67; 95% CI, 0.37–7.46; I 2  = 0%), transient ischemic attack (TIA) (CEA: 0% [n = 0/98]; CAS: 4.2% [n = 7/166]; OR, 0.28; 95% CI, 0.03–2.52; I 2  = 0%), death (CEA: 1.5% [n = 8/523]; CAS: 0.9% [n = 4/431]; OR, 1.41; 95% CI, 0.43–4.58; I 2  = 0%), and cranial nerve injury (CEA: 5.8% [n = 3/51]; CAS: 0% [n = 0/51]; OR, 4.74; 95% CI, 0.5–44.98; I 2  =0%). A subgroup comparing CEA with transfemoral protected CAS showed that patients in the CEA group had a statistically significant lower risk of 30-day stroke (OR, 0.31; 95% CI, 0.17–0.57; I 2  = 30.8%). Conclusions This study shows that CEA is associated with a statistically significant lower risk of 30-day stroke in the elderly population compared with transfemoral CAS with distal or proximal protection. No differences were noted in the rates of periprocedural TIA, MI, death, and cranial nerve injury between CEA and CAS in the original pooled analysis.