A Cochrane review included 16 studies with a total of 7 572 subjects. In patients with symptomatic carotid stenosis at standard surgical risk, endovascular treatment (carotid angioplasty and stenting) was associated with a higher risk of the following outcome measures occurring between randomisation and 30 days after treatment than endarterectomy: death or any stroke (the primary safety outcome) OR 1.72, 95% CI 1.29 to 2.31; death or any stroke or myocardial infarction OR 1.44, 95% CI 1.15 to 1.80; any stroke OR 1.81, 95% CI 1.40 to 2.34. The OR for the primary safety outcome was 1.16 (95% CI 0.80 to 1.67) in patients < 70 years old and 2.20 (95% CI 1.47 to 3.29) in patients ≥ 70 years old (interaction P = 0.02). The rate of death or major or disabling stroke did not differ significantly between treatments (OR 1.28, 95% CI 0.93 to 1.77). Endovascular treatment was associated with lower risks of myocardial infarction (OR 0.44, 95% CI 0.23 to 0.87), cranial nerve palsy (OR 0.08, 95% CI 0.05 to 0.14), and access site haematomas (OR 0.37, 95% CI 0.18 to 0.77).
The combination of death or any stroke up to 30 days after treatment or ipsilateral stroke during follow-up (the primary combined safety and efficacy outcome) favoured endarterectomy (OR 1.39, 95% CI 1.10 to 1.75), but the rate of ipsilateral stroke after the peri-procedural period did not differ between treatments (OR 0.93, 95% CI 0.60 to 1.45). Restenosis during follow-up was more common in patients receiving endovascular treatment than in patients assigned surgery (OR 2.41, 95% CI 1.28 to 4.53; I² = 55%).
In patients with asymptomatic carotid stenosis, there was no statistically significant difference in the occurrence of the primary safety outcome between endovascular treatment and endarterectomy (OR 1.71, 95% CI 0.78 to 3.76) but the point estimate of the OR was nearly identical to the same comparison in symptomatic patients. In the primary combined safety and efficacy outcome, there was a similar non-significant difference favouring surgery (OR 1.75, 95% CI 0.92 to 3.33). Among patients not suitable for surgery, the rate of death or any stroke between randomisation and end of follow-up did not differ significantly between endovascular treatment and medical care (OR 0.22, 95% CI 0.01 to 7.92; I² = 79%).