Published online before print January 23, 2003, doi: 10.1161/01.STR.0000054671.71777.C7
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
(Stroke. 2003;34:514.)
© 2003 American Heart Association, Inc.
Original Contributions |
Reanalysis of the Final Results of the European Carotid Surgery Trial
From the Stroke Prevention Research Unit, University Department of Clinical Neurology, Radcliffe Infirmary, Oxford (P.M.R., S.A.G.), and Department of Clinical Neurosciences, Western General Hospital, Edinburgh (C.P.W.), UK.
Correspondence to Dr P.M. Rothwell, Stroke Prevention Research Unit, University Department of Clinical Neurology, Radcliffe Infirmary, Woodstock Rd, Oxford OX2 6HE UK. E-mail peter.rothwell{at}clneuro.ox.ac.uk
Background and Purpose— The European Carotid Surgery Trial (ECST) and North American Symptomatic Carotid Endarterectomy Trial (NASCET) have shown that endarterectomy reduces the risk of stroke in certain patients with recently symptomatic carotid stenosis. However, they differed in the degree of stenosis above which surgery was reported to be effective. This disparity has led to inconsistent clinical recommendations but may have been due to differences between the trials in the methods of measurement of carotid stenosis and definitions of outcome events.
Methods— To allow direct comparison of analyses from ECST and NASCET, we remeasured the prerandomization ECST carotid angiograms and redefined the outcome events the same way as in NASCET.
Results— We randomized 3018 patients and followed them up for a mean of 73 months. Surgery reduced the 5-year risk of any stroke or surgical death by 5.7% (95% CI, 0 to 11.6) in patients with 50% to 69% stenosis (n=646, P=0.05) and by 21.2% (95% CI, 12.9 to 29.4) in patients with 70% to 99% stenosis without "near occlusion" (n=429, P<0.0001). These benefits were maintained at the 10-year follow-up. However, surgery was of no benefit in patients (n=125) with near occlusion. The effect of surgery in this group was highly significantly different from that in patients with 70% to 99% stenosis without near occlusion (P=0.002). Surgery was harmful in patients with <30% stenosis (n=1321, P=0.007) and of no benefit in patients with 30% to 49% stenosis (n=478, P=0.6).
Conclusions— Results of the ECST and NASCET were consistent when analyzed in the same way. In ECST, surgery was highly beneficial for 70% to 99% stenosis and moderately beneficial for 50% to 69% stenosis. However, contrary to clinical recommendations and current practice, surgery was of little benefit in patients with carotid near occlusion.
Key Words: carotid endarterectomy • randomized controlled trials • stroke prevention
This article has been cited by other articles:
 |
|
 |
|
  J. M. Wardlaw, M. D. Stevenson, F. Chappell, P. M. Rothwell, J. Gillard, G. Young, S. M. Thomas, G. Roditi, and M. J. Gough Carotid Artery Imaging for Secondary Stroke Prevention: Both Imaging Modality and Rapid Access to Imaging Are Important Stroke, November 1, 2009; 40(11): 3511 - 3517. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 R Lin, M Mazighi, J Yadav, and A Abou-Chebl The impact of timing on outcomes of carotid artery stenting in recently symptomatic patients JNIS, October 30, 2009; (2009) jnis.2009.000901v1. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
H. J.M. Barnett Reflections on the Carotid Artery: 438 BC to 2009 AD: The Karolinska 2008 Award Lecture in Stroke Research Stroke, September 1, 2009; 40(9): 3143 - 3148. [Full Text] [PDF]
|
|
|
|
 |
|
 F. Sassi and M. McKee Do clinicians always maximize patient outcomes? A conjoint analysis of preferences for carotid artery testing J Health Serv Res Policy, April 1, 2008; 13(2): 61 - 66. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. L. Brown, T. M. Sundt III, and B. J. Gersh Indications for Revascularization Card. Surg. Adult, January 1, 2008; 3(2008): 551 - 572. [Full Text]
|
|
|
|
 |
|
 J. F. Meschia, T. G. Brott, and R. W. Hobson II Diagnosis and Invasive Management of Carotid Atherosclerotic Stenosis Mayo Clin. Proc., July 1, 2007; 82(7): 851 - 858. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 H.-L. Kao, M.-S. Lin, C.-S. Wang, Y.-H. Lin, L.-C. Lin, C.-L. Chao, J.-S. Jeng, P.-K. Yip, and S.-C. Chen Feasibility of Endovascular Recanalization for Symptomatic Cervical Internal Carotid Artery Occlusion J. Am. Coll. Cardiol., February 20, 2007; 49(7): 765 - 771. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 N. Yamada, M. Higashi, R. Otsubo, T. Sakuma, N. Oyama, R. Tanaka, K. Iihara, H. Naritomi, K. Minematsu, and H. Naito Association between Signal Hyperintensity on T1-Weighted MR Imaging of Carotid Plaques and Ipsilateral Ischemic Events AJNR Am. J. Neuroradiol., February 1, 2007; 28(2): 287 - 292. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. Chaturvedi and J. S. Yadav The Role of Antiplatelet Therapy in Carotid Stenting for Ischemic Stroke Prevention Stroke, June 1, 2006; 37(6): 1572 - 1577. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J.N.E. Redgrave, J.K. Lovett, P.J. Gallagher, and P.M. Rothwell Histological Assessment of 526 Symptomatic Carotid Plaques in Relation to the Nature and Timing of Ischemic Symptoms: The Oxford Plaque Study Circulation, May 16, 2006; 113(19): 2320 - 2328. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
G. S. Roubin, S. Iyer, A. Halkin, J. Vitek, and C. Brennan Realizing the Potential of Carotid Artery Stenting: Proposed Paradigms for Patient Selection and Procedural Technique Circulation, April 25, 2006; 113(16): 2021 - 2030. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. H. Heijenbrok-Kal, E. Buskens, P. J. Nederkoorn, Y. van der Graaf, and M. G. M. Hunink Optimal Peak Systolic Velocity Threshold at Duplex US for Determining the Need for Carotid Endarterectomy: A Decision Analytic Approach Radiology, December 21, 2005; (2005) 2381041078. [Abstract] [Full Text]
|
|
|
|
|
|
N. Nighoghossian, L. Derex, and P. Douek The Vulnerable Carotid Artery Plaque: Current Imaging Methods and New Perspectives Stroke, December 1, 2005; 36(12): 2764 - 2772. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
B. A. Wasserman, R. J. Wityk, H. H. Trout III, and R. Virmani Low-Grade Carotid Stenosis: Looking Beyond the Lumen With MRI Stroke, November 1, 2005; 36(11): 2504 - 2513. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 S. Chaturvedi, A. Bruno, T. Feasby, R. Holloway, O. Benavente, S. N. Cohen, R. Cote, D. Hess, J. Saver, J. D. Spence, et al. Carotid endarterectomy--An evidence-based review: Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology Neurology, September 27, 2005; 65(6): 794 - 801. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. J. Fox, M. Eliasziw, P. M. Rothwell, M. H. Schmidt, C. P. Warlow, H. J.M. Barnett, and for the North American Symptomatic Carotid Endarte Identification, Prognosis, and Management of Patients with Carotid Artery Near Occlusion AJNR Am. J. Neuroradiol., September 1, 2005; 26(8): 2086 - 2094. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. E. Heiserman Measurement Error of Percent Diameter Carotid Stenosis Determined by Conventional Angiography: Implications for Noninvasive Evaluation AJNR Am. J. Neuroradiol., September 1, 2005; 26(8): 2102 - 2107. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
N. Anzalone, F. Scomazzoni, R. Castellano, L. Strada, C. Righi, L. S. Politi, M. A. Kirchin, R. Chiesa, and G. Scotti Carotid Artery Stenosis: Intraindividual Correlations of 3D Time-of-Flight MR Angiography, Contrast-enhanced MR Angiography, Conventional DSA, and Rotational Angiography for Detection and Grading Radiology, July 1, 2005; 236(1): 204 - 213. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C. P. Derdeyn, E. Buskens, P. J. Nederkoorn, Y. van der Graaf, and M. G. M. Hunink Conventional Angiography Remains an Important Tool for Measurement of Carotid Arterial Stenosis * Dr Buskens and colleagues respond: Radiology, May 1, 2005; 235(2): 711 - 713. [Full Text] [PDF]
|
|
|
|
 |
|
 S R Messe, S E Kasner, Z Mehta, C P Warlow, P M Rothwell, and for the European Carotid Surgery Trialists Effect of body size on operative risk of carotid endarterectomy J. Neurol. Neurosurg. Psychiatry, December 1, 2004; 75(12): 1759 - 1761. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
T. G. Brott, R. D. Brown Jr, F. B. Meyer, D. A. Miller, H. J. Cloft, and T. M. Sullivan Carotid Revascularization for Prevention of Stroke: Carotid Endarterectomy and Carotid Artery Stenting Mayo Clin. Proc., September 1, 2004; 79(9): 1197 - 1208. [Abstract] [PDF]
|
|
|
|
|
|
G. Ghilardi, M. L. Biondi, O. Turri, E. Guagnellini, and R. Scorza Internal Carotid Artery Occlusive Disease and Polymorphisms of Fractalkine Receptor CX3CR1: A Genetic Risk Factor Stroke, June 1, 2004; 35(6): 1276 - 1279. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. D. Ecker, M. A. Pichelmann, I. Meissner, and F. B. Meyer Durability of Carotid Endarterectomy Stroke, December 1, 2003; 34(12): 2941 - 2944. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P.M. Rothwell, S.C. Howard, and J.D. Spence Relationship Between Blood Pressure and Stroke Risk in Patients With Symptomatic Carotid Occlusive Disease Stroke, November 1, 2003; 34(11): 2583 - 2590. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. Crane and N. Cheshire Recent developments in vascular surgery BMJ, October 18, 2003; 327(7420): 911 - 915. [Full Text] [PDF]
|
|