Comparative safety and efficacy of invasive therapies for carotid artery stenosis: a systematic review and network meta-analysis

Clinical Snapshot

Key Findings

• P Value: Not reported

• Effect Size: Not quantified in abstract

• Primary Outcome: Short-term stroke risk significantly lower with CEA compared to CAS

• Nnt Or Sensitivity: Not calculated

• Confidence Interval: Not reported

Clinical Application

All three interventions are available in major Australian centres, though TCAR availability may be limited to specialized neurointerventional centres Relevant to Australian practice where CEA and CAS are established treatments covered by Medicare. TCAR adoption may depend on TGA approval and PBS listing. Results support current RACGP guidelines emphasizing individualized treatment selection Patients with carotid artery stenosis requiring revascularization, particularly those at high surgical risk where treatment choice is uncertain

Abstract

BACKGROUND: Carotid artery stenosis is a major cause of stroke and is commonly treated with carotid endarterectomy (CEA) or carotid artery stenting (CAS). Trans-carotid artery revascularization (TCAR) has emerged as a newer alternative designed to reduce the risk of procedural stroke. However, comparative evidence on the safety and efficacy of these interventions is limited. This study evaluates the clinical outcomes of CEA, CAS, and TCAR in patients with carotid artery stenosis. METHODS: A comprehensive search of multiple databases was conducted to identify relevant studies. The outcomes were stroke, mortality, and myocardial infarction, cranial nerve injury, hematoma, infection, transient ischemic attack, and length of hospital stay. Meta-analysis and a frequentist graph-theoretical approach network meta-analysis were performed using the netmeta package in R platform. Risk of bias was assessed using RoB 2 Cochrane and ROBINS-I. RESULTS: Fifty-five studies were included in the review. The short-term stroke risk was significantly lower with CEA than with CAS. TCAR had a potential long-term mortality benefit over CAS, while no significant differences were observed in short-term mortality or myocardial infarction across treatments. CAS was associated with lower risks of cranial nerve injury, hematoma, and infection compared with CEA. CONCLUSION: CEA and TCAR offer better short-term stroke protection than CAS, with TCAR showing promise for long-term mortality benefits. CAS has advantages in reducing cranial nerve injury, hematoma, and infection risks. Overall, the choice of treatment should consider both efficacy and safety profiles. Further high-quality randomized controlled trials, particularly focusing on TCAR, are needed to validate these comparative outcomes. PROSPERO REGISTRY NUMBER: CRD420251055287.

References

1. 1.Amran, M. Y., Fitrah, Y. A., Larassaphira, N. P., Gunawan, A. M. A. K., Abdillah, A. M. H., Toaha, A. R. M., Zainal, A. T. F., & Gunadi, S. G. A. (2026). Comparative safety and efficacy of invasive therapies for carotid artery stenosis: a systematic review and network meta-analysis. Journal of Neurointerventional Surgery. https://doi.org/10.1136/jnis-2025-023900