Clinical characteristics and medical versus interventional management of carotid artery webs: a systematic review and meta-analysis

Background A carotid web (CaW) is a 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. Objective To synthesize the literature and report the clinical characteristics and management outcomes of patients with CaWs. Methods A systematic literature review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. Results 33 studies comprising 737 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 National Institutes of Health Stroke Scale (NIHSS) admission score of 7.5. Atherosclerotic plaques and intramural thrombi were each 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%. In total, treatment outcomes were available for 376 patients with 448 symptomatic CaWs (227 medical, 221 interventional). Medical therapy consisted of antiplatelet or anticoagulation medications, while interventional treatment included carotid artery stenting (CAS), carotid endarterectomy (CEA), and internal carotid artery resection and primary anastomosis (ICRA). The interventional group was associated with a significantly lower risk of recurrent ischemic events compared with the medical group (interventional 0%, medical 36.1%; OR 14.18, 95% CI 3.17 to 63.46, P=0.001) over a mean follow-up of 21.2 months. The odds ratio of cerebral ischemic event recurrence was correlated with the need for thrombectomy at the first event and history of dyslipidemia. Conclusions Most CaWs were found during stroke work-up. Prevention of secondary ischemic events was superior in the interventional management group (CAS, CEA, ICRA) compared with the medical management group.