Temporal trends in short- and long-term outcomes after carotid interventions for symptomatic or asymptomatic stenosis: a systematic review and meta-analysis

INTRODUCTION: In meta-analyses of large cohorts, a decline in procedural risks after carotid endarterectomy (CEA) was found. It remains unclear whether these trends extent to smaller cohorts, carotid artery stenting (CAS), and how long-term outcomes have evolved. PATIENTS AND METHODS: PubMed and EMBASE were searched until 18 November 2024, for studies reporting on 100 or more adults undergoing CEA or CAS for symptomatic or asymptomatic carotid stenosis. Primary outcomes were 30-day and long-term risk of stroke or death. We performed separate analyses in smaller cohorts of < 500 patients. RESULTS: 291 studies reported 475,266 patients undergoing CEA (214,526 symptomatic, 260,740 asymptomatic) and 209,117 undergoing CAS (77,133 symptomatic, 131,984 asymptomatic). Short-term stroke or death after CEA declined 36% (RR = 0.64, 95% CI, 0.63-0.64) per 5-year later treatment midyear in symptomatic and 41% (RR = 0.59, 95% CI, 0.59-0.59) in asymptomatic patients, with consistent trends in smaller cohorts.For CAS, short-term risks declined 44% (RR = 0.56, 95% CI, 0.53-0.58) in symptomatic, and 27% (RR = 0.73, 95% CI, 0.71-0.74) in asymptomatic patients, with consistent trends in smaller cohorts. Long-term death risk after CEA increased 26% (RR = 1.26, 95% CI, 1.20-1.32) and 11% in smaller cohorts. Long-term stroke risk after CAS increased 30% (RR = 1.30, 95% CI, 1.17-1.43) and 44% in smaller cohorts. CONCLUSIONS: Short-term risks after CEA and CAS have decreased over time, also in smaller cohorts. Long-term death after CEA and stroke after CAS have increased. The increased long-term risk of death after CEA and stroke after CAS limits the durability of carotid interventions and warrants further scrutiny.