Carotid endarterectomy for symptomatic carotid stenosis
Kittipan Rerkasem1, Peter M Rothwell
1Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand, 50200.
Insights
Carotid endarterectomy benefits patients with 50-99% stenosis, especially those with severe narrowing. Surgery is not recommended for near-occlusions or less than 30% stenosis.
Area of Science:
- Neurology
- Vascular Surgery
- Evidence-Based Medicine
Background:
- Severe carotid artery stenosis is a significant risk factor for stroke.
- Carotid endarterectomy is a surgical option to reduce stroke risk, but carries potential complications.
Purpose of the Study:
- To compare the benefits and risks of carotid endarterectomy plus medical management versus medical management alone.
- To evaluate outcomes in patients with recent symptomatic carotid stenosis (transient ischaemic attack or non-disabling stroke).
Main Methods:
- Systematic review and pooled analysis of individual patient data from three randomized controlled trials.
- Inclusion of 6092 patients with 35,000 patient-years of follow-up.
- Reassessment of carotid angiograms and outcomes to ensure comparability.
Main Results:
- Carotid endarterectomy showed significant benefit for stenosis between 70%-99% (16.0% ARR) and marginal benefit for 50%-69% stenosis (4.6% ARR).
- No significant benefit was observed for stenosis <30% or near-occlusions.
- Surgical benefit was greatest in men, older patients (≥75 years), and those operated on within two weeks of symptom onset.
Conclusions:
- Carotid endarterectomy is beneficial for symptomatic stenosis of 50%-99%, particularly higher grades, in surgically-fit patients with low complication rates.
- The timing of surgery after symptom onset influences benefit.
- Long-term benefit for near-occlusions remains uncertain.
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.
Related Concept Videos
01:27Coronary Artery Disease V: Interprofessional Care
01:26Aneurysm III: Interprofessional Care
01:26Atherosclerosis III: Management
01:27Peripheral Artery Disease III: Interprofessional Care
01:27Atherosclerosis II: Clinical Manifestations and Diagnostic Tests
01:26Angina IV: Management