Revascularization Plus Medical Therapy Versus Medical Therapy Alone for Asymptomatic Carotid Stenosis: A Meta-Analysis
In brief
Carotid procedures cut long-term stroke 34% but raise early stroke risk 4.5-fold
Across six trials involving 8,276 people with asymptomatic carotid narrowing, adding surgery or stenting to medical therapy was linked to 34% fewer strokes and 20% lower long-term mortality. But in the first 30 to 44 days, stroke risk was 4.5 times higher and mortality nearly four times higher; differences among trials and evolving medical therapy make careful patient selection essential.
- Journal
- Journal of neuroimaging : official journal of the American Society of Neuroimaging (Q1)
- Published
- 1 January 2026
- Study design
- Systematic review / meta-analysis of RCTs
- Evidence level
- Level 1, High (CEBM 1a)
- Authors
- Mohammed M Al-Salihi, Maryam S Al-Jebur, Adam Rizvi, Ahmed Saleh, Ufuk Erginoglu, Farhan Siddiq, et al.
- PMID
- 42806719
- DOI
- 10.1111/jon.70148
Why clinicians should know about it
- Picked for Radiation Oncology (top studies of the week, 4 October 2026): Not relevant to radiation oncology
- Picked for Neurology (clinical) (top studies of the week, 4 October 2026): Meta‑analysis guides asymptomatic carotid stenosis treatment decisions
- Picked for Radiology, Radiation Oncology, Nuclear Medicine, Medical Physics and Imaging (top studies of the week, 4 October 2026): Meta-analysis of carotid revascularization, no imaging focus
- Picked for Surgery (top studies of the week, 4 October 2026): Carotid stenosis meta‑analysis, vascular surgery not core focus
Abstract
BACKGROUND: Management of asymptomatic carotid stenosis (ACS) remains controversial, particularly as contemporary optimal medical therapy (OMT) has evolved beyond the aspirin-based regimens used in earlier trials. We performed a meta-analysis comparing carotid revascularization plus OMT versus OMT alone in patients with ACS. METHODS: We searched five databases (PubMed, Embase, Web of Science, Scopus, and the Cochrane Central Register of Controlled Trials [CENTRAL]) from inception to November 2025. Randomized controlled trials comparing carotid revascularization (endarterectomy or stenting) plus OMT versus OMT alone were included. Primary outcomes were 30- to 44-day mortality and stroke. Other outcomes included long-term all-cause mortality, stroke, myocardial infarction, and intracerebral hemorrhage. All statistical analyses were performed in R, and risk ratios (RRs) with 95% confidence intervals (CIs) were pooled using either fixed- or random-effects models. RESULTS: Six trials involving 8276 patients were included. Revascularization significantly increased 30- to 44-day mortality (RR 3.98 [95% CI, 1.53-10.35], p = 0.0046) and stroke risk (RR 4.53 [95% CI, 2.51-8.17], p < 0.0001). However, long-term follow-up demonstrated significant reductions in all-cause mortality (RR 0.80 [95% CI, 0.68-0.93], p = 0.0053) and stroke (RR 0.66 [95% CI, 0.57-0.76], p < 0.0001). No significant differences were observed in myocardial infarction or intracerebral hemorrhage rates. CONCLUSIONS: Carotid revascularization combined with OMT was associated with increased periprocedural risks but lower long-term stroke and mortality in pooled analyses of patients with ACS. These findings should be interpreted cautiously given differences across trials and evolving OMT standards. Patient selection should balance procedural risks against potential long-term benefit, particularly among patients with high-grade stenosis, low periprocedural risk, and access to experienced centers.
Abstract as published, via PubMed.
For healthcare professionals. The summary is generated by AI from the published abstract, and the evidence level is assigned automatically from the study design on the Oxford CEBM hierarchy. Neither is medical advice. Read the full paper before changing practice.