Clinical Characteristics and Medical versus Interventional Management of Carotid Artery Webs: a Systematic Review and Meta-analysis

Introduction: Carotid web (CaW) is non-atheromatous, shelf-like intraluminal projection, commonly affecting the internal carotid artery. It can be associated with embolic stroke, particularly in younger patients without traditional stroke risk factors. The natural history of CaW is not well-established. Several studies have reported on outcomes after interventional and medical therapy with variable results. We synthesized the literature and reported the clinical characteristics and management outcomes of patients with CaWs.

Methods: A systematic literature review was performed according to the PRISMA guidelines.

Results: 33 studies comprising 739 patients (mean age 50.2 years, female 59.4%, African American 65%) with 835 CaWs were included. The majority of the CaWs were symptomatic (72.9%) with a mean NIHSS admission score of 7.5. Each of atherosclerotic plaques and intramural thrombi were present in 33% of patients. The classic atherosclerotic and stroke risk factors were prevalent as follows (hypertension 37.8%, diabetes 14.6%, smoking 21.7%, dyslipidemia 16.7%, coronary artery disease 6.9%, history of transient ischemic attack 11.9%, atrial fibrillation 4.6%, myocardial infarction 2%). In total, treatment outcomes were available for 448 patients with symptomatic CaWs (227 medical, 221 interventional). Medical therapy consisted of antiplatelet medications or anticoagulants while interventional included carotid artery stenting (CAS) in 139 (63%), carotid endarterectomy (CEA) in 69 (31.2%) and internal carotid artery resection and anastomosis (ICRA) in 13 (5.8%) patients. The interventional group was associated with significantly lower risk of recurrent ischemic events compared to the medical group (interventional: 0 %, medical: 36.1%, RD = -0.49,CI:-0.71--0.27,p < 0.001) over a 25-month mean follow-up. The most common complication of CAS was intra-operative bradycardia (5%) while for CEA transient cranial nerve XII paresis was reported in 3.7%. Direct comparisons between CAS and CEA were not feasible.

Conclusion : Prevention of secondary ischemic events is superior in the interventional (CAS, CEA, ICRA) compared to the medical management group. Future studies are needed to compare CAS vs CEA and identify if one approach is safer and more durable and investigate the optimal management of asymptomatic CaWs.