Cerebral protection devices reduce periprocedural strokes during carotid angioplasty and stenting: a systematic review of the current literature

J Endovasc Ther. 2009 Aug;16(4):412-27. doi: 10.1583/09-2713.1.


Purpose: To compare through a systematic review of published literature the stroke outcomes in protected and unprotected carotid artery stenting (CAS).

Methods: PubMed and Cochrane electronic databases were queried to identify peer-reviewed publications from 1995 to 2007 meeting our pre-defined criteria for inclusion (English language, human only, at least 20 patients reported) and exclusion (procedures performed for the treatment of total occlusion, dissection, or aneurysmal disease; urgently performed procedures; use of covered stents; access other than transfemoral). Information was collected on a standardized data abstraction form for pooled analysis of total strokes within 30 days of procedure in all patients and in symptomatic and asymptomatic subgroups. A random effects meta-analysis of studies with concurrently reported data on protected and unprotected CAS was performed.

Results: Initial database query resulted in 2485 articles, of which 134 were included in the final analyses (12,263 protected CAS patients and 11,198 unprotected CAS patients). Twenty-four studies included data on both protected and unprotected CAS. Using pooled analysis of all 134 reports, the relative risk (RR) for stroke was 0.62 (95% CI 0.54 to 0.72) in favor of protected CAS. Subgroup analysis revealed a significant benefit for protected CAS in both symptomatic (RR 0.67; 95% CI 0.52 to 0.56) and asymptomatic (RR 0.61; 95% CI 0.41 to 0.90) patients (p<0.05). Meta-analysis of the 24 studies reporting data on both protected and unprotected stenting demonstrated a relative risk of 0.59 (95% CI 0.47 to 0.73) for stroke, again favoring protected CAS (p<0.001).

Conclusion: Our systematic review indicated that the use of cerebral protection devices decreased the risk of perioperative stroke with CAS. A well designed randomized trial can further confirm our findings and possibly indicate the device with the best outcomes.

Publication types

  • Meta-Analysis
  • Review
  • Systematic Review

MeSH terms

  • Angioplasty / adverse effects
  • Angioplasty / instrumentation*
  • Angioplasty / mortality
  • Carotid Artery Diseases / mortality
  • Carotid Artery Diseases / surgery*
  • Evidence-Based Medicine
  • Humans
  • Intracranial Embolism / etiology
  • Intracranial Embolism / mortality
  • Intracranial Embolism / prevention & control*
  • Prosthesis Design
  • Risk Assessment
  • Risk Factors
  • Stents*
  • Stroke / etiology
  • Stroke / mortality
  • Stroke / prevention & control*
  • Treatment Outcome