Carotid Endarterectomy, Stenting, or Medical Therapy in Asymptomatic Carotid Stenosis

Introduction: The question of whether carotid endarterectomy (CEA) or carotid artery stenting (CAS) offers a net advantage over best medical therapy (BMT) alone has not been rigorously characterized across the full trial evidence base, particularly when accounting for procedural risk. Hypothesis: BMT alone confers superior short-term safety over revascularization, whereas CEA and CAS provide durable post-procedural stroke prevention; however, the net long-term benefit of revascularization is attenuated in contemporary trial cohorts. Methods: A Bayesian network meta-analysis using random-effects models and Markov Chain Monte Carlo estimation was conducted. Randomized controlled trials evaluating a three-node network (CEA, CAS, BMT alone) for asymptomatic high-grade carotid stenosis (typically ≥60-70%) were included. Primary outcomes were 30-day perioperative stroke and long-term ipsilateral stroke. A pre-specified sensitivity analysis was restricted to trials published in 2000 or later. Analyses were performed in R version 4.6.0. Results: Sixteen trials comprising 34 study arms and 16,145 patients were included. For 30-day stroke, BMT alone demonstrated the most favorable short-term safety profile (SUCRA 1.00), followed by CEA (SUCRA 0.47) and CAS (SUCRA 0.03). Compared with BMT alone, perioperative stroke risk was higher with CAS (OR 5.08, 95% CI 2.90-8.93) and CEA (OR 3.48, 95% CI 2.16-5.62), while CAS also carried a greater procedural risk than CEA (OR 1.46, 95% CI 1.06-2.00). During long-term follow-up, CEA demonstrated the most favorable durability profile for prevention of ipsilateral stroke (P-score 0.81), whereas CAS (P-score 0.69) and BMT alone (P-score 0.00) ranked lower. Compared with BMT alone, long-term ipsilateral stroke risk was reduced following CEA (OR 0.37, 95% CI 0.29-0.48) and CAS (OR 0.39, 95% CI 0.26-0.59). Findings were directionally consistent in analyses restricted to trials published in 2000 or later. However, when perioperative procedural events were incorporated into longitudinal outcomes, the overall long-term advantage of CEA versus BMT alone was attenuated and no longer statistically significant (OR 0.79, 95% CI 0.55-1.12), despite preservation of the post-procedural durability benefit in the contemporary cohort (OR 0.38, 95% CI 0.28-0.52). Conclusions: Carotid revascularization is associated with an upfront procedural stroke risk but provides durable reduction in ipsilateral stroke after the perioperative period. In contemporary trial cohorts, attenuation of the net long-term benefit supports intensive medical therapy as a reasonable primary management strategy for many asymptomatic patients, particularly when procedural risk offsets downstream absolute benefit.