Q) What is the better option between carotid endarterectomy (CEA) vs carotid stent (CAS) for treating a patient with severe cervical internal carotid artery (ICA) stenosis with contralateral ICA occlusion (CCO)? 

A) We actually don’t know the answer to this question yet. We don’t have randomized controlled trials comparing CAS and CEA in patients with CCO.

B) A systemic review and meta-analysis of CEA vs CAS for patients with CCO (2018) which included 5 observational studies (6346 patients) showed no difference in either techniques in stroke, myocardial infarction and major adverse cardiovascular events. However, patients who had CEA had significantly lower risk of 30-day mortality rate (OR=0.46, CI: 0.30-0.71, I2 = 0%). They couldn’t exclude selection bias since patients who underwent CAS were generally sicker. One study included in the analysis showed that the CAS group had more patients with congestive heart failure and COPD. 

C) Overall, the literature is inconclusive regarding whether or not CCO status increases the risk for periprocedural adverse events during CEA or CAS. 

D) NASCET and ACAS studies showed that CCO is a risk factor for 30-day mortality and other adverse cerebrovascular events after CEA, but patients with CCO in these studies were small in number. 

E) A meta-analysis and meta-regression analysis of 43 studies and 96,658 patients, 6144/75,857 in CEA and  6144/20,801 in CAS group had CCO. Patients with CCO had higher risk of 30-day mortality in both the CAS and CEA group. However, only the CEA group had increased risk of preoperative stroke and TIA in CCO patients compared to non-CCO patients.

Reference: 

  1. Kokkinidis DG, Chaitidis N, Giannopoulos S, Texakalidis P, Haider MN, Aronow HD, Giri JS, Armstrong EJ. Presence of Contralateral Carotid Occlusion Is Associated With Increased Periprocedural Stroke Risk Following CEA but Not CAS: A Meta-analysis and Meta-regression Analysis of 43 Studies and 96,658 Patients. J Endovasc Ther. 2020 Apr;27(2):334-344.  

  1. Texakalidis P, Giannopoulos S, Kokkinidis DG, Karasavvidis T, Rangel-Castilla L, Reavey-Cantwell J. Carotid Artery Endarterectomy Versus Carotid Artery Stenting for Patients with Contralateral Carotid Occlusion: A Systematic Review and Meta-Analysis. World Neurosurg. 2018 Dec;120:563-571.