Value of carotid endarterectomy in asymptomatic patients - includes editor comment - adapted from th

Author: Caroline Wellberry
Date: Oct, 1995

The benefits of carotid endarterectomy are well established in symptomatic patients with stenosis greater than 70 percent. The Asymptomatic Carotid Atherosclerosis Study compared medical and surgical outcomes in asymptomatic patients with stenosis greater than 60 percent.

In this multicenter trial, 1,662 patients were selected from a pool of 42,000 on the basis of eligibility criteria, which included absence of ipsilateral cerebrovascular events and good surgical candidacy. After elimination of patients who were lost to follow-up or who ultimately did not want surgery or had unexpected surgical risk, 724 patients underwent carotid endarterectomy and 834 received medical treatment only. Patients who underwent surgery received the same medical treatment as patients who were managed medically, including treatment with aspirin, 325 mg per day, and counseling to reduce risk factors. The cohort was followed for a mean of 2.7 years.

Perioperative risk, defined as morbidity and mortality due to arteriography, and cerebral infarction or death up to 30 days after carotid endarterectomy, was 2.3 percent for patients in the surgical group. In the medical group, over a comparable period, the risk for the same endpoints was only 0.4 percent. This statistical disadvantage in the surgical group disappeared at 10 months, when the stroke rate of 2.2 percent in the medical group began to offset early mortality in the surgical group. This trend reached statistical significance at three years. The five-year risk of ipsilateral stroke (including perioperative mortality) based on statistical projections was estimated at 11 percent for the medical group and 5.1 percent for the surgical group. Different approaches to the data, including consideration of secondary endpoints, such as any stroke or death, showed similar results.

The researchers conclude that carotid endarterectomy is effective in reducing the five-year event rate in asymptomatic patients with stenosis of 60 percent or more. The degree of reduction was lower in women than in men and depended on whether perioperative mortality was included in the analysis. Thus, event reduction was as low as 17 percent for women when perioperative complications were included and as high as 79 percent in men when perioperative events were excluded. (JAMA, May 10, 1995, vol. 273, p. 1421.)

EDlTOR'S NOTE: The practical implications of this study are yet to be determined. Detection of asymptomatic stenosis is not simple, and the high cost of screening and surgery may obviate the use of preventive carotid endarterectomy. Finally, patients may not be willing to trade perioperative complications for possible long-term benefits.

COPYRIGHT 1995 American Academy of Family PhysiciansCOPYRIGHT 2004 Gale Group

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