Benefit of Carotid Endarterectomy in Patients with Symptomatic Moderate or Severe Stenosis
Henry J.M. Barnett, M.D., D. Wayne Taylor, M.A., Michael Eliasziw, Ph.D., Allan J. Fox, M.D., Gary G. Ferguson, M.D., R. Brian Haynes, M.D., Richard N. Rankin, M.D., G. Patrick Clagett, M.D., Vladimir C. Hachinski, M.D., David L. Sackett, M.D., Kevin E. Thorpe, M.Math., Heather E. Meldrum, B.A., J. David Spence, M.D., for The North American Symptomatic Carotid Endarterectomy Trial Collaborators
Background Previous studies have shown that carotid endarterectomyin patients with symptomatic severe carotid stenosis (definedas stenosis of 70 to 99 percent of the luminal diameter) isbeneficial up to two years after the procedure. In this clinicaltrial, we assessed the benefit of carotid endarterectomy inpatients with symptomatic moderate stenosis, defined as stenosisof less than 70 percent. We also studied the durability of thebenefit of endarterectomy in patients with severe stenosis overeight years of follow-up.
Methods Patients who had moderate carotid stenosis and transientischemic attacks or nondisabling strokes on the same side asthe stenosis (ipsilateral) within 180 days before study entrywere stratified according to the degree of stenosis (50 to 69percent or <50 percent) and randomly assigned either to undergocarotid endarterectomy (1108 patients) or to receive medicalcare alone (1118 patients). The average follow-up was five years,and complete data on outcome events were available for 99.7percent of the patients. The primary outcome event was any fatalor nonfatal stroke ipsilateral to the stenosis for which thepatient underwent randomization.
Results Among patients with stenosis of 50 to 69 percent, thefive-year rate of any ipsilateral stroke (failure rate) was15.7 percent among patients treated surgically and 22.2 percentamong those treated medically (P=0.045); to prevent one ipsilateralstroke during the five-year period, 15 patients would have tobe treated with carotid endarterectomy. Among patients withless than 50 percent stenosis, the failure rate was not significantlylower in the group treated with endarterectomy (14.9 percent)than in the medically treated group (18.7 percent, P=0.16).Among the patients with severe stenosis who underwent endarterectomy,the 30-day rate of death or disabling ipsilateral stroke persistingat 90 days was 2.1 percent; this rate increased to only 6.7percent at 8 years. Benefit was greatest among men, patientswith recent stroke as the qualifying event, and patients withhemispheric symptoms.
Conclusions Endarterectomy in patients with symptomatic moderatecarotid stenosis of 50 to 69 percent yielded only a moderatereduction in the risk of stroke. Decisions about treatment forpatients in this category must take into account recognizedrisk factors, and exceptional surgical skill is obligatory ifcarotid endarterectomy is to be performed. Patients with stenosisof less than 50 percent did not benefit from surgery. Patientswith severe stenosis (70 percent) had a durable benefit fromendarterectomy at eight years of follow-up.
Source Information
From the John P. Robarts Research Institute, London, Ont. (H.J.M.B., M.E., H.E.M.); the Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ont. (D.W.T., R.B.H., K.E.T.); the Departments of Clinical Epidemiology and Biostatistics (M.E.), Diagnostic Radiology and Nuclear Medicine (A.J.F., R.N.R.), and Clinical Neurological Sciences (H.J.M.B., A.J.F., G.G.F., V.C.H.), University of Western Ontario, London; the Department of Surgery, University of Texas Southwestern Medical Center, Dallas (G.P.C.); and the Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom (D.L.S.). J. David Spence, M.D., Department of Clinical Neurological Sciences, University of Western Ontario, London, was also an author.
Address reprint requests to Dr. Barnett at the John P. Robarts Research Institute, P.O. Box 5015, 100 Perth Dr., London, ON N6A 5K8, Canada.
Carotid Endarterectomy
Goldstein L. B., Saver J. L., Elkins J. S., Shekelle P. G., Park R.E., Chassin M. R., Haynes R. B., Barnett H. J.M., Taylor D. W., Tu J. V.
Extract |
Full Text
N Engl J Med 1999;
340:1209-1212, Apr 15, 1999.
Correspondence
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(2007). Cardiovascular Risk Factors and Ultrasound Evaluation of Intima-Media Thickness at Common Carotids, Carotid Bulbs, and Femoral and Abdominal Aorta Arteries in Patients with Classic Congenital Adrenal Hyperplasia due to 21-Hydroxylase Deficiency. J. Clin. Endocrinol. Metab.
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Yamada, N., Higashi, M., Otsubo, R., Sakuma, T., Oyama, N., Tanaka, R., Iihara, K., Naritomi, H., Minematsu, K., Naito, H.
(2007). Association between Signal Hyperintensity on T1-Weighted MR Imaging of Carotid Plaques and Ipsilateral Ischemic Events. Am. J. Neuroradiol.
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Bates, E. R., Babb, C. J. D., Casey, D. E., Cates, C. U., Duckwiler, G. R., Feldman, T. E., Gray, W. A., Ouriel, K., Peterson, E. D., Rosenfield, K., Rundback, J. H., Safian, R. D., Sloan, M. A., White, C. J.
(2007). ACCF/SCAI/SVMB/SIR/ASITN 2007 Clinical Expert Consensus Document on Carotid Stenting: A Report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents (ACCF/SCAI/SVMB/SIR/ASITN Clinical Expert Consensus Document Committee on Carotid Stenting). Vasc Med
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(2007). Endarterectomy and Stenting for Asymptomatic Carotid Stenosis: A Race at Breakneck Speed. Stroke
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Feasby, T. E., Barnett, H.J.M.
(2007). Improving the appropriateness of carotid endarterectomy. Neurology
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Halm, E. A., Tuhrim, S., Wang, J. J., Rojas, M., Hannan, E. L., Chassin, M. R.
(2007). Has evidence changed practice?: Appropriateness of carotid endarterectomy after the clinical trials. Neurology
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[Abstract][Full Text]
American Society of Interventional & Therapeutic N, , Society for Cardiovascular Angiography and Interve, , Society for Vascular Medicine and Biology, , Society of Interventional Radiology, , Bates, E. R., Babb, J. D., Casey, D. E. Jr, Cates, C. U., Duckwiler, G. R., Feldman, T. E., Gray, W. A., Ouriel, K., Peterson, E. D., Rosenfield, K., Rundback, J. H., Safian, R. D., Sloan, M. A., White, C. J., Harrington, R. A., Abrams, J., Anderson, J. L., Bates, E. R., Eisenberg, M. J., Grines, C. L., Hlatky, M. A., Lichtenberg, R. C., Lindner, J. R., Pohost, G. M., Schofield, R. S., Shubrooks, S. J. JR, Stein, J. H., Tracy, C. M., Vogel, R. A., Wesley, D. J.
(2007). ACCF/SCAI/SVMB/SIR/ASITN 2007 Clinical Expert Consensus Document on Carotid Stenting: A Report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents (ACCF/SCAI/SVMB/SIR/ASITN Clinical Expert Consensus Document Committee on Carotid Stenting). J Am Coll Cardiol
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Lell, M., Fellner, C., Baum, U., Hothorn, T., Steiner, R., Lang, W., Bautz, W., Fellner, F.A.
(2007). Evaluation of Carotid Artery Stenosis with Multisection CT and MR Imaging: Influence of Imaging Modality and Postprocessing. Am. J. Neuroradiol.
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Turk, A.S., Johnson, K.M., Lum, D., Niemann, D., Aagaard-Kienitz, B., Consigny, D., Grinde, J., Turski, P., Haughton, V., Mistretta, C.
(2007). Physiologic and Anatomic Assessment of a Canine Carotid Artery Stenosis Model Utilizing Phase Contrast with Vastly Undersampled Isotropic Projection Imaging. Am. J. Neuroradiol.
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(2006). Outlook Commentaries. PERSPECT VASC SURG ENDOVASC THER
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Tawakol, A., Migrino, R. Q., Bashian, G. G., Bedri, S., Vermylen, D., Cury, R. C., Yates, D., LaMuraglia, G. M., Furie, K., Houser, S., Gewirtz, H., Muller, J. E., Brady, T. J., Fischman, A. J.
(2006). In Vivo 18 F-Fluorodeoxyglucose Positron Emission Tomography Imaging Provides a Noninvasive Measure of Carotid Plaque Inflammation in Patients. J Am Coll Cardiol
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[Abstract][Full Text]
70 percent) had a durable benefit from endarterectomy at eight years of follow-up. 
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