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Short term and intermediate term comparison of endarterectomy versus stenting for carotid artery stenosis: systematic review and meta-analysis of randomised controlled clinical trials

BMJ 2010; 340 doi: (Published 12 February 2010) Cite this as: BMJ 2010;340:c467

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  1. Pascal Meier, clinical and research fellow12,
  2. Guido Knapp, senior scientist3,
  3. Umesh Tamhane, research fellow1,
  4. Seemant Chaturvedi, professor of neurology4,
  5. Hitinder S Gurm, assistant professor of cardiology12
  1. 1University of Michigan Cardiovascular Center, Floor 2A 394, 1500 E Medical Center Drive, Ann Arbor, MI 48109-5853, USA
  2. 2Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI
  3. 3Department of Statistics, TU Dortmund University, Dortmund, Germany
  4. 4Wayne State University/Detroit Medical Center, Department of Neurology, Detroit, MI, USA
  1. Correspondence to: H S Gurm hgurm{at}
  • Accepted 14 December 2009


Objective To evaluate the relative short term safety and intermediate term efficacy of carotid endarterectomy versus carotid artery stenting.

Design Systematic review and meta-analysis.

Data sources BIOSIS, Embase, Medline, the Cochrane central register of controlled trials, International Pharmaceutical Abstracts database, ISI Web of Science, and Google scholar and bibliographies, from 1 January 1990 to 25 July 2009.

Study selection Randomised controlled trials comparing carotid endarterectomy with carotid artery stenting in patients with carotid artery stenosis with or without symptoms.

Data extraction Primary end point was a composite of mortality or stroke. Secondary end points were death, stroke, myocardial infarction, or facial neuropathy (as individual end points), and mortality or disabling stroke (as a composite end point).

Data synthesis 11 trials were included (4796 patients); 10 reported on short term outcomes (n=4709) and nine on intermediate term outcomes (1-4 years). The periprocedural risk of mortality or stroke was lower for carotid endarterectomy (odds ratio 0.67, 95% confidence interval 0.47 to 0.95; P=0.025) than for carotid stenting, mainly because of a decreased risk of stroke (0.65, 0.43 to 1.00; P=0.049), whereas the risk of death (1.14, 0.56 to 2.31; P=0.727) and the composite end point mortality or disabling stroke (0.74, 0.53 to 1.05; P=0.088) did not differ significantly. The odds of periprocedural myocardial infarction (2.69, 1.06 to 6.79; P=0.036) or cranial nerve injury (10.2, 4.0 to 26.1; P<0.001) was higher in the carotid endarterectomy group than in the carotid stenting group. In the intermediate term, the two treatments did not differ significantly for stroke or death (hazard ratio 0.90, 95% confidence interval 0.74 to 1.1; P=0.314).

Conclusions Carotid endarterectomy was found to be superior to carotid artery stenting for short term outcomes but the difference was not significant for intermediate term outcomes; this difference was mainly driven by non-disabling stroke. Significantly fewer cranial nerve injuries and myocardial infarctions occurred with carotid artery stenting.


  • We thank Whitney Townsend (librarian, Taubman Medical Library, University of Michigan) for her inputs and help during the literature search and Don Cutlip (Beth Israel Hospital, Harvard Medical School) for providing data on the SAPPHIRE trial.

  • Contributors: HSG and PM conceived and designed the study. HSG, PM, GK, and SC analysed and interpreted the data. PM drafted the paper. HSG, SC, GK, and UT revised the paper critically for important intellectual content. All authors had full access to the data (including statistical reports and tables) in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. All authors also approved the final version to be published. HSG and PM are guarantors for this study.

  • Funding: PM is supported by a postdoctoral fellowship grant from the Swiss National Research Foundation and the Schweizerische Stiftung für Medizinisch-Biologische Stipendien. The funding organisation had no role in the design and conduct of the study; the collection, management, analysis, and interpretation of the data; or the preparation, review, or approval of the manuscript.

  • Competing interests: SC is a consultant for Abbott Vascular.

  • Ethical approval: Not required.

  • Data sharing: Datasets and statistical code for R and SAS are available from the corresponding author at hgurm{at}

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