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(Stroke. 2000;31:2037.)
© 2000 American Heart Association, Inc.

Original Contributions

Long-Term Clinical and Angiographic Outcomes in Symptomatic Patients With 70% to 99% Carotid Artery Stenosis

Maurizio Paciaroni, MD; Michael Eliasziw, PhD; Brenda L. Sharpe, BScN; L. Jaap Kappelle, MD; Seemant Chaturvedi, MD; Heather Meldrum, BA; Henry J.M. Barnett, MD for the North American Symptomatic Carotid Endarterectomy Trial (NASCET) Group

From the Department of Neuroscience (M.P.), University of Perugia, Perugia, Italy; The John P. Robarts Research Institute (M.P., M.E., B.L.S., H.M., H.J.M.B.) and the Departments of Epidemiology and Biostatistics (M.E.) and Clinical Neurological Sciences (M.E., H.J.M.B.), University of Western Ontario, London, Ontario, Canada; the Department of Neurology (L.J.K.), University Medical Centre, Utrecht, the Netherlands; and the Department of Neurology (S.C.), Wayne State University, Detroit, Mich.

Correspondence to H.J.M. Barnett, MD, The John P. Robarts Research Institute, PO Box 5015, 100 Perth Dr, London, Ontario, Canada N6A 5K8. E-mail barnett{at}rri.on.ca

Background and Purpose—In 1991, the North American Symptomatic Carotid Endarterectomy Trial (NASCET) reported the benefit of carotid endarterectomy for 659 patients with 70% to 99% stenosis. Follow-up continued until 1997.

Methods—The present study examined the risks and causes of ipsilateral stroke in the randomized groups and in those who had delayed endarterectomy or continued on medical therapy and also examined the evolution of carotid disease on follow-up imaging.

Results—By on-treatment (efficacy) analysis, the risk of any ipsilateral stroke at 3 years was 28.3% for medically randomized and 8.9% for surgically randomized patients (19.4% absolute risk reduction, P<0.001). For combined disabling or fatal ipsilateral stroke, the risks were 14.0% and 3.4%, respectively (10.6% absolute risk reduction). In medical patients, >80% of the first strokes at 3 years were of large-artery origin. After February 1991, 116 suitable medical patients underwent endarterectomy within 6 months, and 115 continued on medical therapy. The 3-year risk of any ipsilateral stroke in the groups of 116 and 115 patients was 7.9% and 15.0%, respectively (7.1% absolute risk reduction). During follow-up, 81 patients had angiograms comparable to the baseline images. Progression by 10% occurred in 7 patients; regression, in 8; no change, in 39; and occlusion, in 27. By use of both angiography and ultrasound, 63 (25.5%) of the 247 medically treated patients progressed to occlusion, of whom 31.7% had an ipsilateral stroke before or on the day of occlusion.

Conclusions—Endarterectomy for patients with 70% to 99% stenosis and recent symptoms was efficacious in the long term. Compared with patients who continued on medical therapy, medical patients with delayed endarterectomy experienced a moderate benefit. Medically treated patients experienced a high risk of occlusion.

Key Words: carotid stenosis • cerebral ischemia • endarterectomy • occlusion

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