Systematic review and network meta-analysis of treatment strategies for asymptomatic carotid disease

We aim to perform a systematic review and meta-analysis to investigate outcomes of treatment strategies for asymptomatic carotid disease. We searched electronic bibliographic sources (MEDLINE, EMBASE, CINAHL and CENTRAL) to identify randomised controlled trials (RCT) reporting comparative outcomes of carotid endarterectomy (CEA), carotid stenting (CAS) and best medical therapy (BMT) in asymptomatic carotid disease. We performed pairwise meta-analysis applying random or fixed-effects models and reported the results as the odds ratio (OR) or risk difference (RD) and 95% confidence interval (CI). We also performed a network meta-analysis and obtained a hierarchy of the competing interventions using rankograms and the surface under the cumulative ranking curve and mean ranks. Stroke and death within 30 days and during follow up were the primary outcome endpoints. Eleven RCTs were identified reporting a total of 8,954 patients. Compared to BMT, CEA reduces the odds of long-term mortality (OR 0.70, 95% CI 0.43, 1.12) and ipsilateral stroke (OR 0.59 95% CI 0.50, 0.71). Network meta-analyses league table demonstrated that BMT is superior to CEA and CAS in terms of perioperative stroke risk and mortality. CEA is the preferred method to reduce the long-term risk of ipsilateral stroke and mortality for patients with asymptomatic carotid disease.