Carotid endarterectomy for symptomatic carotid stenosis

Rerkasem K, Rothwell PM

Published Online:

April 13, 2011

Strokes cause long-term disability and death. The chances of dying are much higher with subsequent strokes, which often occur within one year of the first attack. Strokes are often associated with blockages and severe narrowing in the internal carotid and other large blood vessels carrying oxygenated blood from the heart to the brain. Surgical removal of the fatty deposits and blood clots from inside the carotid artery wall may reduce the risk of stroke but carries a risk of peri-operative complications including disabling stroke and death. This review identified three randomised controlled trials, which included over 6000 patients who were mostly elderly, predominantly male, had a recent non-disabling stroke or transient ischaemic attack and had confirmed narrowing of the appropriate carotid artery. Many of the participants had heart disease, diabetes and high blood pressure. Increased degree of narrowing, advanced age, male sex and recent transient ischaemic attack or stroke were associated with increasing benefit from surgery. Patients with lesser degrees of narrowing were harmed.

Abstract (click to read)

Background:

Severe narrowing (stenosis) of the carotid artery is an important cause of stroke. Surgical treatment (carotid endarterectomy) may reduce the risk of stroke, but carries a risk of operative complications.

Objectives:

To determine the balance of benefit versus risk of endarterectomy plus best medical management compared with best medical management alone in patients with a recent symptomatic carotid stenosis (i.e. transient ischaemic attack (TIA) or non-disabling stroke).

Search strategy:

We searched the Cochrane Stroke Group Trials Register (July 2010), MEDLINE (1966 to March 2010), EMBASE (1990 to March 2010) and three other databases, and handsearched relevant journals and reference lists.

Selection criteria:

Randomised controlled trials.

Data collection and analysis:

Two review authors independently selected studies and extracted the data.

Main results:

We included three trials. As the trials differed in the methods of measurement of carotid stenosis and in the definition of stroke, we did a pooled analysis of individual patient data on 6092 patients (35,000 patient years of follow-up) after reassessment of the carotid angiograms and outcomes from all three trials using the primary electronic data files and redefined outcome events where necessary to achieve comparability.

On re-analysis, there were no statistically significant differences between the trials in the risks of any of the main outcomes in either of the treatment groups or in the effects of surgery. Surgery increased the five-year risk of ipsilateral ischaemic stroke in patients with less than 30% stenosis (N = 1746, absolute risk reduction (ARR) -2.2%, P = 0.05), had no significant effect in patients with 30% to 49% stenosis (N = 1429, ARR 3.2%, P = 0.6), was of marginal benefit in patients with 50% to 69% stenosis (N = 1549, ARR 4.6%, P = 0.04), and was highly beneficial in patients with 70% to 99% stenosis without near-occlusion (N = 1095, ARR 16.0%, P < 0.001). However, there was no evidence of benefit (N = 262, ARR -1.7%, P = 0.9) in patients with near-occlusions.

Benefit from surgery was greatest in men, patients aged 75 years or over, and patients randomised within two weeks after their last ischaemic event and fell rapidly with increasing delay.

Authors' conclusions:

Endarterectomy is of some benefit for 50% to 69% symptomatic stenosis and highly beneficial for 70% to 99% stenosis without near-occlusion. Benefit in patients with carotid near-occlusion is marginal in the short-term and uncertain in the long-term. These results are generalisable only to surgically-fit patients operated on by surgeons with low complication rates (less than 7% risk of stroke and death). Benefit from endarterectomy depends not only on the degree of carotid stenosis, but also on several other factors, including the delay to surgery after the presenting event.

This record should be cited as:

Rerkasem K, Rothwell PM. Carotid endarterectomy for symptomatic carotid stenosis. Cochrane Database of Systematic Reviews 2011, Issue 4. Art. No.: CD001081. DOI: 10.1002/14651858.CD001081.pub2

Assessed as up to date:

October 27, 2010

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Primary Review Group:

Stroke Group

Health topics:

Heart & circulation > Stroke > Ischemic stroke/TIA: prevention

Neurology > Stroke > Ischemic stroke/TIA: prevention

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Independent high-quality evidence for health care decision making

Carotid endarterectomy for symptomatic carotid stenosis

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