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Carotid endarterectomy for asymptomatic carotid stenosis: a meta-analysis
1Department of Medicine, Division of Neurology, University of Texas Health Science Center, San Antonio, TX 78284-7883, USA. benavente@uthscsa.edu
Insights
Carotid endarterectomy significantly reduces stroke risk in patients with asymptomatic carotid stenosis. However, the absolute benefit is small, making medical management a sensible alternative for most.
Area of Science:
- Neurology
- Vascular Surgery
- Preventive Medicine
Background:
- Asymptomatic carotid stenosis poses a risk for ischemic stroke.
- Carotid endarterectomy is a surgical intervention to prevent stroke.
- The net benefit of this surgery in asymptomatic patients requires careful evaluation.
Purpose of the Study:
- To evaluate the effectiveness of carotid endarterectomy in preventing stroke among patients with asymptomatic carotid stenosis.
- To quantify the risks and benefits associated with the procedure.
Main Methods:
- Systematic review and meta-analysis of randomized controlled trials.
- Inclusion of 2440 patients from five trials with stenosis greater than or equal to 50%.
- Comparison of carotid endarterectomy versus medical treatment alone.
Main Results:
- Carotid endarterectomy led to a significant reduction in ipsilateral stroke risk (OR 0.62).
- An absolute risk reduction of 2% for stroke was observed over approximately 3.1 years.
- A notable increase in perioperative stroke or death was identified (OR 4.51).
Conclusions:
- Carotid endarterectomy unequivocally reduces ipsilateral stroke incidence in asymptomatic carotid stenosis patients, but the absolute benefit is modest.
- Routine recommendation for unselected patients is not supported.
- Medical management is a viable alternative for the majority of patients.
Objective:
To assess the value of carotid endarterectomy for prevention of stroke in patients with asymptomatic carotid stenosis.
Design:
Systematic review and meta-analysis of randomised controlled trials in patients with asymptomatic carotid stenosis in which subjects were allocated to carotid endarterectomy or to medical treatment alone.
Subjects:
Five trials enrolled 2440 patients with stenosis >/ 50%.
Main Outcome Measures:
Stroke ipsilateral to the stenosis, all strokes, and perioperative complications (stroke or death).
Results:
In patients who underwent carotid endarterectomy (n=1215) there was a significant reduction in the odds of ipsilateral stroke plus perioperative stroke or death (odds ratio 0.62; 95% confidence interval 0.44 to 0.86), corresponding to a 2% absolute risk reduction over about 3.1 years. The prevalence of stroke in any location was also reduced (0.68; 0.51 to 0.9) in patients undergoing carotid endarterectomy. During the immediate postoperative period there was an increased prevalence of stroke or death among such patients (4.51; 2.36 to 8.64).
Conclusion:
Carotid endarterectomy in patients with asymptomatic carotid stenosis unequivocally reduces the incidence of ipsilateral stroke, though the absolute benefit is relatively small. Given the modest benefit of surgery for unselected patients with asymptomatic carotid artery stenosis carotid endarterectomy cannot be routinely recommended for these patients pending reliable identification of high risk subgroups, and medical management is a sensible alternative for most patients.