Medical treatment versus endarterectomy for symptomatic carotid stenosis: systematic review and meta-analysis.

Introduction: The treatment of symptomatic carotid stenosis traditionally relies on revascularization procedures. However, evolution of medical treatment over the last decades, prompted the possibility to consider a best medical treatment approach as viable for the management of low-risk symptomatic patients. Nevertheless, there is limited evidence on the long-term outcomes of symptomatic patients treated medically, being critical to reassess the risk-benefit balance of invasive procedures in addition to best medical treatment. This study aims to review evidence on long-term outcomes of symptomatic carotid stenosis patients treated with best medical treatment alone and assess whether additional revascularization offers any beneficial effects.

Evidence acquisition: A systematic review was performed according to the recommendations of the Preferred Reporting Items for Systematic reviews and Meta-analysis statement and guidelines.

Evidence synthesis: There was a trend for a higher risk of stroke (pooled risk of 6.96% [95% confidence interval (CI): 4.76-9.15%]), death (pooled risk of 3.14% [95% CI: 1.64-4.64%]), and the combined outcome of stroke or death (pooled risk of 8.91% [95% CI: 6.49-11.33%]) in the medical group compared to patients undergoing revascularization procedures: 4.51% (95% CI: 2.67-6.35%), 2.65% (95% CI: 1.23-4.08%), and 6.56% (95% CI: 4.37-8.76%), respectively.

Conclusions: While best medical treatment has undergone significant advancements in recent decades, there is scarce data regarding the long-term outcomes of symptomatic patients receiving such treatment. Future research investigating the treatment of symptomatic carotid stenosis by surgery or endovascular methods should incorporate medical treatment arms to accurately assess the incidence of recurrent events in patients undergoing best medical treatment in the long-term.