A Systematic Review and Updated Metaanalysis for Carotid Near-Occlusion

Ann Vasc Surg. 2020 Jul:66:636-645.e3. doi: 10.1016/j.avsg.2019.10.093. Epub 2019 Nov 7.


Background: Carotid near-occlusion (CNO) is distal luminal collapse of the internal carotid artery beyond a tight stenosis. CNO is a relatively rare condition accounting for 3% in symptomatic carotid stenosis and about 20% in severe (≥70%) symptomatic stenosis. The optimal treatment for CNO remains controversial.

Methods: This systematic review and metaanalysis were performed in accordance with the Meta-analysis of Observational Studies in Epidemiology guidelines (MOOSE). We searched MEDLINE, the Cochrane Library, and EMBASE for articles published from inception date to November 2018. Methodological Index for Non-randomized Studies (MINORS) was used to evaluate the methodological quality of studies. We defined primary outcome as any stroke, death and myocardial infarction (MI) within 30 days after intervention and the operative risks of carotid endarterectomy (CEA) and carotid artery stenting (CAS) were evaluated by the incidence rate (IR) of the primary outcome. Secondary outcome was defined as ipsilateral stroke, neurogenic or cardiac death and MI during the follow-up. Long-term risk was evaluated by the IR of secondary outcome. The analyses used the IRs of secondary outcome and restenosis per person-year (p-y) were performed to evaluate long-term risk and restenosis. Pooled analyses of different therapy groups were calculated.

Results: Twenty-eight articles of 26 studies met the inclusion criteria and were eligible for pooled analysis. Pooled IR of secondary outcome was 4.26 per 100 p-ys (95% CI, 2.92-6.20 per 100 p-ys) in intervention group (heterogeneity, I2 = 56.1%, P < 0.01; Egger test, P = 0.73) and 13.3 per 100 p-ys (95% CI, 5.54-31.95 per 100 p-ys) in best medical treatment (BMT) group (heterogeneity, I2 = 88.3%, P < 0.01; Egger test, P = 0.76). No significant difference was demonstrated in operative risk (CEA: 4.82%, 95% confidence interval [CI]: 3.07-7.55%; CAS: 5.39%, 95% CI: 3.69-7.88%) and long-term risk (CEA: 4.47 per 100 p-ys, 95% CI: 3.35-5.97 per 100 p-ys; CAS: 4.71 per 100 p-ys, 95% CI: 2.37-9.37 per 100 p-ys) between CEA and CAS group.

Conclusions: BMT alone may be not enough to support a better prognosis than CEA or CAS for patients with CNO. No significant difference was found between patients with CNO who underwent CAS and CEA in both perioperative period and long-term follow-up.

Publication types

  • Meta-Analysis
  • Systematic Review

MeSH terms

  • Carotid Artery, Internal / diagnostic imaging
  • Carotid Artery, Internal / physiopathology
  • Carotid Artery, Internal / surgery*
  • Carotid Stenosis / diagnostic imaging
  • Carotid Stenosis / mortality
  • Carotid Stenosis / physiopathology
  • Carotid Stenosis / therapy*
  • Endarterectomy, Carotid* / adverse effects
  • Endarterectomy, Carotid* / mortality
  • Endovascular Procedures* / adverse effects
  • Endovascular Procedures* / instrumentation
  • Endovascular Procedures* / mortality
  • Humans
  • Postoperative Complications / mortality
  • Postoperative Complications / therapy
  • Risk Assessment
  • Risk Factors
  • Severity of Illness Index
  • Stents
  • Time Factors
  • Treatment Outcome