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.
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N Engl J Med 1999;
340:1209-1212, Apr 15, 1999.
Correspondence
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(2005). Absence of Microemboli on Transcranial Doppler Identifies Low-Risk Patients With Asymptomatic Carotid Stenosis. Stroke
36: 2373-2378
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Wasserman, B. A., Wityk, R. J., Trout, H. H. III, Virmani, R.
(2005). Low-Grade Carotid Stenosis: Looking Beyond the Lumen With MRI. Stroke
36: 2504-2513
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Kadkhodayan, Y., Jeck, D. T., Moran, C. J., Derdeyn, C. P., Cross, D. T. III
(2005). Angioplasty and Stenting in Carotid Dissection with or without Associated Pseudoaneurysm. Am. J. Neuroradiol.
26: 2328-2335
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Heijenbrok-Kal, M. H., Nederkoorn, P. J., Buskens, E., van der Graaf, Y., Myriam Hunink, M.G.
(2005). Diagnostic Performance of Duplex Ultrasound in Patients Suspected of Carotid Artery Disease: The Ipsilateral Versus Contralateral Artery. Stroke
36: 2105-2109
[Abstract][Full Text]
Chaturvedi, S., Bruno, A., Feasby, T., Holloway, R., Benavente, O., Cohen, S. N., Cote, R., Hess, D., Saver, J., Spence, J. D., Stern, B., Wilterdink, J.
(2005). Carotid endarterectomy--An evidence-based review: Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology
65: 794-801
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Kern, R., Steinke, W., Daffertshofer, M., Prager, R., Hennerici, M.
(2005). Stroke recurrences in patients with symptomatic vs asymptomatic middle cerebral artery disease. Neurology
65: 859-864
[Abstract][Full Text]
Fox, A. J., Eliasziw, M., Rothwell, P. M., Schmidt, M. H., Warlow, C. P., Barnett, H. J.M., for the North American Symptomatic Carotid Endarte,
(2005). Identification, Prognosis, and Management of Patients with Carotid Artery Near Occlusion. Am. J. Neuroradiol.
26: 2086-2094
[Abstract][Full Text]
Bates, B., Choi, J. Y., Duncan, P. W., Glasberg, J. J., Graham, G. D., Katz, R. C., Lamberty, K., Reker, D., Zorowitz, R.
(2005). Veterans Affairs/Department of Defense Clinical Practice Guideline for the Management of Adult Stroke Rehabilitation Care: Executive Summary. Stroke
36: 2049-2056
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Harrod-Kim, P., Kadkhodayan, Y., Derdeyn, C. P., Cross, D. T. III, Moran, C. J.
(2005). Outcomes of Carotid Angioplasty and Stenting for Radiation-Associated Stenosis. Am. J. Neuroradiol.
26: 1781-1788
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Gaitini, D., Soudack, M.
(2005). Diagnosing Carotid Stenosis by Doppler Sonography: State of the Art. J Ultrasound Med
24: 1127-1136
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Kim, H. C., Nam, C. M., Jee, S. H., Suh, I.
(2005). Comparison of Blood Pressure-Associated Risk of Intracerebral Hemorrhage and Subarachnoid Hemorrhage: Korea Medical Insurance Corporation Study. Hypertension
46: 393-397
[Abstract][Full Text]
Wright, V. L., Olan, W., Dick, B., Yu, H., Alberts-Grill, N., Latour, L. L., Baird, A. E.
(2005). Assessment of CE-MRA for the rapid detection of supra-aortic vascular disease. Neurology
65: 27-32
[Abstract][Full Text]
Bibl, D., Lampl, C., Biberhofer, I., Kerschner, K., Kypta, A., Bergmann, J., Kaindlstorfer, A., Roper, C., Yazdi, K., Engleder, C., Hofmann, R., Deibl, M., Leisch, F., Ransmayr, G.
(2005). Internal carotid artery stent placement without emboli protection: Results and long-term outcome. Neurology
65: 132-134
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Durward, Q. J., Ragnarsson, T. S., Reeder, R. F., Case, J. L., Hughes, C. A.
(2005). Carotid Endarterectomy in Nonagenarians. Arch Surg
140: 625-628
[Abstract][Full Text]
Chang, J. B., Stein, T. A., Eliasziw, M., Alamowitch, S., Barnett, H. J.M.
(2005). The Risk and Benefit of Endarterectomy In Women With Symptomatic Internal Carotid Artery Disease * Response:. Stroke
36: 1357-1358
[Full Text]
Alberts, M. J., Latchaw, R. E., Selman, W. R., Shephard, T., Hadley, M. N., Brass, L. M., Koroshetz, W., Marler, J. R., Booss, J., Zorowitz, R. D., Croft, J. B., Magnis, E., Mulligan, D., Jagoda, A., O'Connor, R., Cawley, C. M., Connors, J.J., Rose-DeRenzy, J. A., Emr, M., Warren, M., Walker, M. D., for the Brain Attack Coalition,
(2005). Recommendations for Comprehensive Stroke Centers: A Consensus Statement From the Brain Attack Coalition. Stroke
36: 1597-1616
[Abstract][Full Text]
Deogaonkar, A., Vivar, R., Bullock, R. E., Price, K., Chambers, I., Mendelow, A. D.
(2005). Bispectral index monitoring may not reliably indicate cerebral ischaemia during awake carotid endarterectomy. Br J Anaesth
94: 800-804
[Abstract][Full Text]
Hobson, R. W. II, Brott, T. G., Roubin, G. S., Silver, F. L., Barnett, H. J.M.
(2005). Carotid Artery Stenting: Meeting the Recruitment Challenge of a Clinical Trial. Stroke
36: 1314-1315
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Imai, K., Mori, T., Izumoto, H., Watanabe, M., Majima, K.
(2005). Emergency Carotid Artery Stent Placement in Patients with Acute Ischemic Stroke. Am. J. Neuroradiol.
26: 1249-1258
[Abstract][Full Text]
Derdeyn, C. P., Buskens, E., Nederkoorn, P. J., van der Graaf, Y., Hunink, M. G. M.
(2005). Conventional Angiography Remains an Important Tool for Measurement of Carotid Arterial Stenosis * Dr Buskens and colleagues respond:. Radiology
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Barnett, H. J.M.
(2005). Conventional wisdom vs reality in stroke prevention. Neurology
64: 1122-1124
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70 percent) had a durable benefit from endarterectomy at eight years of follow-up. 
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