Carotid Artery Stenting versus Carotid Artery Endarterectomy in high-risk patients: A systematic review

<ns3:p> Background This systematic review aims to compare the efficacy and safety of carotid artery stenting (CAS) and carotid endarterectomy (CEA) in high-risk patients and to identify gaps in the current evidence regarding their clinical outcomes. Methods A systematic review was conducted in accordance with PRISMA guidelines. Randomised controlled trials and non-randomised comparative studies including high-risk patients, defined as those with elevated perioperative risk due to anatomical, physiological, or comorbid factors, were eligible. PubMed, Embase, Scopus, Web of Science, the Cochrane Library, and ClinicalTrials.gov were searched from inception to September 2025. Two reviewers independently screened studies, extracted data, and assessed risk of bias using standardised criteria. A narrative synthesis was performed to summarise and compare outcomes between CAS and CEA. Results Nine studies involving 4,198 patients were included Peri-procedural stroke rates for CAS ranged from 1.1–9.7%, while those for CEA ranged from 1.4–4.2%, indicating comparable outcomes between the two. Myocardial infarction occurred less frequently with CAS (0–2.4%) than with CEA (up to 6.1%) (p < 0.01). Cranial nerve injury occurred in 0% of CAS cases and up to 4.9% of CEA cases (p < 0.001). Restenosis rates were similar between procedures (CAS 2–4.3% vs. CEA 0.6–2%; p > 0.05). Conclusions Although CAS was associated with lower myocardial infarction and cranial nerve injury rates, the evidence does not conclusively demonstrate the superiority of either procedure in high-risk patients. The absence of stratified analyses for symptomatic versus asymptomatic cohorts’ limits interpretation. Further randomised studies with robust subgroup analyses are required to clarify comparative effectiveness. <ns3:bold>Registration:</ns3:bold> PROSPERO 2025 CRD420251162463 </ns3:p>