This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Rothwell, P.M. Articles by Warlow, C.P. Search for Related Content PubMed PubMed Citation Articles by Rothwell, P.M. Articles by Warlow, C.P.

(Stroke. 1996;27:266-269.)
© 1996 American Heart Association, Inc.

Articles

A Systematic Comparison of the Risks of Stroke and Death Due to Carotid Endarterectomy for Symptomatic and Asymptomatic Stenosis

P.M. Rothwell, MD; J. Slattery, MSc C.P. Warlow, FRCP

From the Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK.

	Abstract

Top Abstract Introduction Methods Results Discussion References

 
Background and Purpose There is some evidence that carotid endarterectomy reduces the risk of ipsilateral carotid territory ischemic stroke in patients with severe asymptomatic carotid stenosis. However, the benefit of endarterectomy is dependent on a low risk of stroke and/or death due to surgery. Whether the low operative risks reported in recent clinical trials and cited in recent guidelines are widely generalizable to clinical practice is unclear. Is endarterectomy for asymptomatic carotid stenosis really safer than surgery for recently symptomatic stenosis?

Methods We performed a systematic review comparing the risks of stroke and death due to carotid endarterectomy, performed by the same surgeons or in the same institutions, for symptomatic and asymptomatic stenosis in studies published since 1980.

Results Twenty-five studies fulfilled our criteria. Mortality within 30 days of endarterectomy was 1.31% for asymptomatic stenosis and 1.81% for symptomatic stenosis (odds ratio [OR], 0.69; 95% confidence interval [CI], 0.49 to 0.99). The risks of fatal stroke were 0.47% and 0.91%, respectively (OR, 0.57; 95% CI, 0.34 to 0.98). The overall risk of stroke and/or death was 3.35% for asymptomatic and 5.18% for symptomatic stenosis (OR, 0.61; 95% CI, 0.51 to 0.74).

Conclusions Mortality and the risk of stroke and/or death due to carotid endarterectomy are significantly lower for asymptomatic than symptomatic stenosis. These findings are consistent across virtually all studies and are likely to be widely generalizable.

Key Words: carotid endarterectomy • carotid stenosis • mortality

	Introduction

Top Abstract Introduction Methods Results Discussion References

 
Carotid endarterectomy reduces the risk of carotid territory ischemic stroke ipsilateral to a recently symptomatic severe (70% to 99%) carotid stenosis.^{1 2} There is now evidence that individuals with asymptomatic carotid stenosis might also benefit from surgery.³ However, the risk of ischemic stroke in the territory of an asymptomatic carotid stenosis on medical treatment has consistently been found to be low,^{4 5} and it is less than half that associated with symptomatic carotid stenosis of similar severity.⁵ The benefit of endarterectomy for asymptomatic carotid stenosis is therefore critically dependent on the morbidity and mortality of surgery. The 50% reduction in stroke risk for patients randomized to endarterectomy in the ACAS study⁶ was the result of very low surgical morbidity and mortality. The risk of stroke and death within 30 days of endarterectomy, excluding the risk of angiography, was 1.5% (95% CI, 0.8 to 2.7). In the VA study,⁷ which did not demonstrate a definite reduction in stroke risk after surgery for asymptomatic stenosis, the risk of stroke and/or death associated with surgery was 4.3% (95% CI, 1.8 to 7.9). The VA result is not significantly different from the risks in the trials of surgery for symptomatic stenosis.^{1 2} Are the low risks of stroke and death in the ACAS study and those studies of surgery for asymptomatic stenosis referenced in recent guidelines⁸ generalizable? Is the risk of stroke and death due to surgery for asymptomatic stenosis genuinely less than that for symptomatic stenosis? To answer these questions, we performed a systematic review of published studies reporting the morbidity and mortality of carotid endarterectomy for symptomatic and asymptomatic stenosis. To ensure that any differences in risk could not be attributed to differences in surgical skill, the analysis was restricted to studies that reported the results of surgery for symptomatic and asymptomatic stenosis performed by the same surgeons or in the same institutions.

	Methods

Top Abstract Introduction Methods Results Discussion References

 
The review was confined to studies published since 1980 to reflect present-day surgical practice. Studies were identified from CD-ROM (Cambridge MEDLINE) using the search terms: "carotid endarterectomy" and "carotid surgery." The Cochrane Collaboration Stroke Database⁹ and the reference lists of all articles identified electronically were also searched. Articles were included if they fulfilled the following criteria: (1) numbers of strokes and deaths occurring within 30 days of carotid endarterectomy (or similar time period) performed for symptomatic and asymptomatic stenosis were reported separately; (2) numbers of operations were clearly defined in each group; (3) symptomatic patients were defined as having suffered a carotid-distribution transient ischemic attack or completed stroke ipsilateral to the stenosis; and (4) endarterectomy for symptomatic and asymptomatic patients was performed by the same surgeons or in the same institutions.

Mortality and the risk of stroke and/or death were defined per operation. The CIs of the absolute risks of death, fatal stroke, and stroke and/or death were calculated using an extrabinomial method to account for any heterogeneity of risk among the individual studies.¹⁰ If there is heterogeneity of risk, standard methods of calculating CIs produce artificially narrow CIs. The overall ORs for death, fatal stroke, and stroke and/or death due to endarterectomy for asymptomatic versus symptomatic stenosis were calculated using the Mantel-Haenszel method.

	Results

Top Abstract Introduction Methods Results Discussion References

 
Twenty-five studies^{11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35} fulfilled the criteria for inclusion in the review. All studies reported the total number of strokes and deaths, but three did not give the number of deaths separately.^{14 31 35} There were no deaths in one study.¹⁹ Thus, the overview of mortality ORs was based on 21 studies including 2521 operations for asymptomatic stenosis and 9529 operations for symptomatic stenosis (Figure), and the overview of stroke and/or death was based on 25 studies including 3139 operations for asymptomatic stenosis and 11 917 operations for symptomatic stenosis (Figure).

View larger version (28K): [in this window] [in a new window]   Figure 1. The odds of death and of stroke and/or death associated with carotid endarterectomy for asymptomatic versus symptomatic carotid stenosis within 25 studies identified from the published literature. The numbers of deaths, strokes, and operations are given; ORs of less than 1 indicate a lower risk for asymptomatic stenosis. For each study, the square represents the OR and the line the 95% CI of the OR. The size of the square is proportional to the variance of the estimate of the relative odds. The diamond represents the overall estimate for all studies combined.

There were 33 deaths (1.31%; 95% CI, 0.80 to 1.78) attributed to endarterectomy for asymptomatic stenosis and 172 deaths (1.81%; CI, 1.46 to 2.13) attributed to surgery for symptomatic stenosis (OR, 0.69; CI, 0.49 to 0.99). The relative odds of death after surgery for asymptomatic versus symptomatic stenosis showed no statistically significant heterogeneity between studies (²=12.6, df=20, P=.90). Two studies gave no information on the causes of death.^{11 24} Among the remainder, the risk of nonstroke death was 0.81% (CI, 0.48 to 2.25) after surgery for asymptomatic stenosis and 0.80% (CI, 0.60 to 0.99) after surgery for symptomatic stenosis. The risk of fatal stroke was 0.47% (CI, 0.20 to 0.79) for asymptomatic stenosis and 0.91% (CI, 0.51 to 1.14) for symptomatic stenosis (OR, 0.57; CI, 0.38 to 0.98).

In no study was the risk of stroke and/or death due to endarterectomy for asymptomatic stenosis statistically significantly lower than the risk for symptomatic stenosis. However, there was a trend toward a lower risk for asymptomatic stenosis in 24 of the 25 studies. The overall risks of stroke and/or death were 3.35% (CI, 2.38 to 4.31) for asymptomatic stenosis and 5.18 (CI, 4.30 to 6.06) for symptomatic stenosis (OR, 0.61; CI, 0.51 to 0.74; Figure). There was no significant heterogeneity between studies in the relative odds of stroke and/or death after surgery for asymptomatic versus symptomatic stenosis (²=13.6, df=24, P=.96).

	Discussion

Top Abstract Introduction Methods Results Discussion References

 
Although no single study demonstrated a statistically significant difference, the overall mortality and risk of stroke and/or death due to carotid endarterectomy for asymptomatic stenosis were significantly lower than for symptomatic stenosis in this systematic review. Indeed, this observation was remarkably consistent across almost all the studies, suggesting that the finding is generalizable. The absolute estimates of risk are susceptible to publication bias and might therefore be underestimates. However, the relative odds of complications after surgery for asymptomatic versus symptomatic stenosis are unlikely to be biased because the comparisons were made within studies. The operations on both groups were performed by the same surgeons or in the same institutions.

The risks of nonstroke death attributed to endarterectomy were almost identical for symptomatic and asymptomatic stenosis. The 40% difference in the overall odds of stroke and death was therefore accounted for by the significantly lower risks of fatal and nonfatal stroke associated with surgery for asymptomatic stenosis.

Why is surgery safer for asymptomatic stenosis than symptomatic stenosis? Symptomatic patients by definition have already suffered a stroke or transient ischemic attack in the distribution of the artery undergoing operation, and the same factors that caused the presenting symptoms, such as intraluminal thrombosis or poor collateral circulation, might also predispose to stroke at surgery. Additionally, clinical characteristics such as age, sex, or the proportion with coexisting cardiac disease may differ between symptomatic and asymptomatic patients. Only one of the 25 studies reviewed compared the characteristics of the two groups of patients.¹⁸ There were no differences. Similarly, the reported baseline characteristics of the patients randomized to surgery in the ACAS and VA asymptomatic trials^{3 8} are almost identical to those in the ECST and NASCET symptomatic studies.^{1 2 36} As far as we can tell, symptomatic and asymptomatic patients appear to have similar clinical characteristics.

The 3.35% overall risk of stroke and/or death due to endarterectomy for asymptomatic stenosis is similar to the 4.3% risk in the VA trial⁸ and is in keeping with the 3% limit set by the American Heart Association.³⁷ It is, however, statistically significantly greater than the 1.5% risk in the ACAS trial.³ This difference is difficult to explain and casts doubt on the generalizability of the ACAS trial results to more routine surgical practice.

In conclusion, the mortality and risk of stroke and/or death due to carotid endarterectomy performed by the same surgeons or in the same institutions are approximately 40% lower for asymptomatic stenosis than symptomatic stenosis. This finding is very consistent and is likely to be widely generalizable.

	Selected Abbreviations and Acronyms

 

ACAS = Asymptomatic Carotid Atherosclerosis Study CI = confidence interval ECST = European Carotid Surgery Trial NASCET = North American Symptomatic Carotid Endarterectomy Trial OR = odds ratio VA = Veterans Affairs (Cooperative Study)

	Acknowledgments

 
This study was funded by the United Kingdom Medical Research Council (Dr Rothwell and Mr Slattery).

	Footnotes

 
Reprint requests to Dr P.M. Rothwell, Department of Clinical Neurosciences, Western General Hospital, Crewe Rd, Edinburgh EH4 2XU, UK. E-mail pmr@skull.dcn.ed.ac.uk.

Received October 3, 1995; revision received November 14, 1995; accepted November 14, 1995.

	References

Top Abstract Introduction Methods Results Discussion References

 

1. European Carotid Surgery Trialists' Collaborative Group. MRC European Carotid Surgery Trial: interim results for symptomatic patients with severe (70-99%) or with mild (0-29%) carotid stenosis. Lancet. 1991;337:1235-1243. [Medline] [Order article via Infotrieve]
2. North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med. 1991;325:445-453. [Abstract]
3. Warlow CP. Endarterectomy for asymptomatic carotid stenosis? Lancet. 1995;345:1254-1255. [Medline] [Order article via Infotrieve]
4. Norris JW, Zhu CZ. Stroke risk and critical carotid stenosis. J Neurol Neurosurg Psychiatry. 1990;53:235-237. [Abstract]
5. European Carotid Surgery Trialists' Collaborative Group. The risk of stroke in the distribution of an asymptomatic carotid artery. Lancet. 1995;345:209-212. [Medline] [Order article via Infotrieve]
6. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. Endarterectomy for asymptomatic carotid artery stenosis. JAMA. 1995;273:1421-1428. [Abstract]
7. Hobson RW II, Weiss DG, Fields WS, Goldstone J, Moore WS, Towne JB, Wright CB, and the Veterans Affairs Cooperative Study Group. Efficacy of carotid endarterectomy for asymptomatic carotid stenosis. N Engl J Med. 1993;328:221-227. [Abstract/Free Full Text]
8. Ad Hoc Committee, American Heart Association. Guidelines for carotid endarterectomy. Stroke. 1995;26:188-201. [Abstract/Free Full Text]
9. Cochrane Database of Systematic Reviews. London, UK: BMJ Publishing; 1995.
10. McCullagh P, Nelder JA. Generalised Linear Models. London, UK: Chapman and Hall; 1989.
11. Whitney DG, Kahn EM, Estes JW, Jones CE. Carotid artery surgery without a temporary indwelling shunt: 1917 consecutive procedures. Arch Surg. 1980;115:1393-1398. [Abstract]
12. Carmichael JD. Carotid surgery in the community hospital: 367 consecutive operations. Arch Surg. 1980;115:937-939. [Abstract]
13. White JS, Sirinek KR, Root D, Rogers W. Morbidity and mortality of carotid endarterectomy. Arch Surg. 1981;116:409-412. [Abstract]
14. Hertzer NR, Beven EG, Modic MT, O'Hara PJ, Vogt DP, Weinstein MA. Early patency of the carotid artery after endarterectomy: digital subtraction angiography after two hundred sixty-two operations. Surgery. 1982;92:1049-1056. [Medline] [Order article via Infotrieve]
15. Haffner CD. Minimising the risks of carotid endarterectomy. J Vasc Surg. 1984;1:392-397. [Medline] [Order article via Infotrieve]
16. Brott T, Thalinger K. The practice of carotid endarterectomy in a large metropolitan area. Stroke. 1984;15:950-955. [Abstract/Free Full Text]
17. Fode NC, Sundt TM, Robertson JT, Peerless SJ, Shields CB. Multicenter retrospective review of results and complications of carotid endarterectomy in 1981. Stroke. 1986;17:370-376. [Abstract/Free Full Text]
18. Kempczinski RF, Brott TG, Labutta RJ. The influence of surgical specialty and caseload on the results of carotid endarterectomy. J Vasc Surg. 1986;3:911-916. [Medline] [Order article via Infotrieve]
19. Sise MJ, Sedwitz MM, Rowley WR, Shackford SR. Prospective analysis of carotid endarterectomy and silent cerebral infarction in 97 patients. Stroke. 1989;20:329-332. [Abstract/Free Full Text]
20. Friedmann P, Garb JL, Berman J, Sullivan C, Celoria G, Rhee SW. Carotid endarterectomy: clinical results in a community-based teaching hospital. Stroke. 1988;19:1323-1327. [Abstract/Free Full Text]
21. Peters RA, Hanson TL, Fontenelle LJ. The influence of resident surgical training on outcome of carotid endarterectomy in a teaching hospital. Surg Gynecol Obstet. 1988;166:487-490. [Medline] [Order article via Infotrieve]
22. AbuRahma AF, Robinson P. Indications and complications of carotid endarterectomy as performed by four different surgical specialty groups. J Cardiovasc Surg (Torino). 1988;29:277-282. [Medline] [Order article via Infotrieve]
23. Kirshner DL, O'Brien MS, Ricotta JJ. Risk factors in a community experience with carotid endarterectomy. J Vasc Surg. 1989;10:178-186. [Medline] [Order article via Infotrieve]
24. Healy DA, Clowes AW, Zierler RE, Nicholls SC, Bergelin RO, Primozich JF, Strandness DE. Immediate and long-term results of carotid endarterectomy. Stroke. 1989;20:1138-1142. [Abstract/Free Full Text]
25. Maini BS, Mullins TF, Catlin J, O'Mara P. Carotid endarterectomy: A ten year analysis of outcome and cost of treatment. J Vasc Surg. 1990;12:732-740. [Medline] [Order article via Infotrieve]
26. Hoyne RF. Review of 272 consecutive carotid endarterectomies in a smaller community. Surg Gynecol Obstet. 1990;170:522-526. [Medline] [Order article via Infotrieve]
27. Burns RJ, Willoughby JO. South Australian carotid endarterectomy study. Med J Aust. 1991;154:650-653. [Medline] [Order article via Infotrieve]
28. Mattos MA, Hodgson KJ, Londrey GL, Barkmeier LD, Ramsey DE, Garfield M, Sumner DS. Carotid endarterectomy: operative risks, recurrent stenosis, and long-term stroke rates in a modern series. J Cardiovasc Surg. 1992;33:387-400. [Medline] [Order article via Infotrieve]
29. Maxwell JG, Covington DL, Churchill MP, Rutherford EJ, Clancy TV, Tackett AD. Results of staged bilateral carotid endarterectomy. Arch Surg. 1992;127:793-799. [Abstract]
30. Perler BA, Burdick JF, Williams GM. Does contralateral internal carotid artery occlusion increase the risk of carotid endarterectomy? J Vasc Surg. 1992;16:347-353. [Medline] [Order article via Infotrieve]
31. McCrory DC, Goldstein LB, Samsa GP, Oddone EZ, Landsman PB, Moore WS, Matchar DB. Predicting complications of carotid endarterectomy. Stroke. 1993;24:1285-1291. [Abstract/Free Full Text]
32. Kadwa AM, Robbs JV. Carotid endarterectomy in Durban: the first 10 years. S Afr Med J. 1993;83:248-252. [Medline] [Order article via Infotrieve]
33. Niak DK, Shirer WC, Stephenson CB, Meech PR. Carotid endarterectomy at Wellington Hospital. N Z Med J. 1994;107:334-335. [Medline] [Order article via Infotrieve]
34. Musser DJ, Nicholas GG, Reed JF. Death and adverse cardiac events after carotid endarterectomy. J Vasc Surg. 1994;19:615-622. [Medline] [Order article via Infotrieve]
35. Riles TS, Imparato AM, Jacobowitz GR, Lamparello PJ, Giangola G, Adelman MA, Landis R. The cause of perioperative stroke after carotid endarterectomy. J Vasc Surg. 1994;19:206-216. [Medline] [Order article via Infotrieve]
36. Barnett HJM, Warlow CP. Carotid endarterectomy and the measurement of carotid stenosis. Stroke. 1993;24:1281-1284. [Free Full Text]
37. Beebe HG, Clagett GP, DeWeese JA, Moore WS, Robertson JT, Sandok B, Wolf PA. Assessing risk associated with carotid endarterectomy: a statement for health professionals by an ad hoc committee on carotid surgery standards of the Stroke Council, American Heart Association. Stroke. 1989;20:314-315.

This article has been cited by other articles:

				J. M. Findlay Editorial Comment--Plaque Pathology and Patient Selection for Carotid Endarterectomy Stroke, February 1, 2005; 36(2): 257 - 258. [Full Text] [PDF]

				R. T. Higashida, P. M. Meyers, C. C. Phatouros, J. J. Connors III, J. D. Barr, D. Sacks, and for the Technology Assessment Committees of the Am Reporting Standards for Carotid Artery Angioplasty and Stent Placement Stroke, May 1, 2004; 35(5): e112 - e134. [Full Text] [PDF]

				V. J. Howard and W. Rosamond Editorial Comment--Identifying Risk Factors for Perioperative Outcomes After Carotid Endarterectomy: The Story Continues Stroke, November 1, 2003; 34(11): 2573 - 2575. [Full Text] [PDF]

				R. Bond, K. Rerkasem, and P.M. Rothwell Systematic Review of the Risks of Carotid Endarterectomy in Relation to the Clinical Indication for and Timing of Surgery Stroke, September 1, 2003; 34(9): 2290 - 2301. [Abstract] [Full Text] [PDF]

				E. A. Halm, M. R. Chassin, S. Tuhrim, L. H. Hollier, A. J. Popp, E. Ascher, H. Dardik, G. Faust, and T. S. Riles Revisiting the Appropriateness of Carotid Endarterectomy Stroke, June 1, 2003; 34(6): 1464 - 1471. [Abstract] [Full Text] [PDF]

				D. J. Fox Jr, C. J. Moran, D. T. Cross III, R. L. Grubb Jr, K. M. Rich, M. R. Chicoine, R. G. Dacey Jr, and C. P. Derdeyn Long-Term Outcome After Angioplasty for Symptomatic Extracranial Carotid Stenosis in Poor Surgical Candidates Stroke, December 1, 2002; 33(12): 2877 - 2880. [Abstract] [Full Text] [PDF]

				H. P. M. van Heesewijk, J. A. Vos, E. S. Louwerse, J. C. van den Berg, T. T. C. Overtoom, S. M. P. G. Ernst, H. W. Mauser, F. L. Moll, and R. G. A. Ackerstaff New Brain Lesions at MR Imaging after Carotid Angioplasty and Stent Placement Radiology, August 1, 2002; 224(2): 361 - 365. [Abstract] [Full Text] [PDF]

				A. Dietz, J. Berkefeld, J. G. Theron, T. Schmitz-Rixen, F. E. Zanella, B. Turowski, H. Steinmetz, and M. Sitzer Endovascular Treatment of Symptomatic Carotid Stenosis Using Stent Placement: Long-Term Follow-Up of Patients With a Balanced Surgical Risk/Benefit Ratio Stroke, August 1, 2001; 32(8): 1855 - 1859. [Abstract] [Full Text] [PDF]

				K. P.N. Forbes, H. A. Shill, P. M. Britt, J. M. Zabramski, R. F. Spetzler, and J. E. Heiserman Assessment of Silent Embolism from Carotid Endarterectomy by Use of Diffusion-weighted Imaging: Work in Progress AJNR Am. J. Neuroradiol., April 1, 2001; 22(4): 650 - 653. [Abstract] [Full Text]

				A. M. Malek, R. T. Higashida, C. C. Phatouros, T. E. Lempert, P. M. Meyers, W. S. Smith, C. F. Dowd, and V. V. Halbach Stent Angioplasty for Cervical Carotid Artery Stenosis in High-Risk Symptomatic NASCET-Ineligible Patients Stroke, December 1, 2000; 31(12): 3029 - 3033. [Abstract] [Full Text] [PDF]

				J. J. Vitek, G. S. Roubin, N. Al-Mubarek, G. New, and S. S. Iyer Carotid Artery Stenting: Technical Considerations AJNR Am. J. Neuroradiol., October 1, 2000; 21(9): 1736 - 1743. [Abstract] [Full Text]

				C. C. Phatouros, R. T. Higashida, A. M. Malek, P. M. Meyers, T. E. Lempert, C. F. Dowd, and V. V. Halbach Carotid Artery Stent Placement for Atherosclerotic Disease: Rationale, Technique, and Current Status Radiology, October 1, 2000; 217(1): 26 - 41. [Abstract] [Full Text]

				L. O'Neill, D. J. Lanska, and A. Hartz Surgeon characteristics associated with mortality and morbidity following carotid endarterectomy Neurology, September 26, 2000; 55(6): 773 - 781. [Abstract] [Full Text] [PDF]

				R. G. A. Ackerstaff, K. G. M. Moons, C. J. W. van de Vlasakker, F. L. Moll, F. E. E. Vermeulen, A. Algra, and M. P. Spencer Association of Intraoperative Transcranial Doppler Monitoring Variables With Stroke From Carotid Endarterectomy Stroke, August 1, 2000; 31(8): 1817 - 1823. [Abstract] [Full Text] [PDF]

				M. Muller, W. Reiche, P. Langenscheidt, J. Ha{beta}feld, and T. Hagen Ischemia after Carotid Endarterectomy: Comparison between Transcranial Doppler Sonography and Diffusion-Weighted MR Imaging AJNR Am. J. Neuroradiol., January 1, 2000; 21(1): 47 - 54. [Abstract] [Full Text] [PDF]

				A G Speers and S K Das Extracranial cerebrovascular disease - a management dilemma Postgrad. Med. J., October 1, 1999; 75(888): 635 - 636. [Full Text]

				P. B. Gorelick Carotid Endarterectomy : Where Do We Draw the Line? Stroke, September 1, 1999; 30(9): 1745 - 1750. [Full Text] [PDF]

				M. A. Weigand, A. Laipple, K. Plaschke, H.-H. Eckstein, E. Martin, and H. J. Bardenheuer Concentration Changes of Malondialdehyde Across the Cerebral Vascular Bed and Shedding of L-Selectin During Carotid Endarterectomy Stroke, February 1, 1999; 30(2): 306 - 311. [Abstract] [Full Text] [PDF]

				C. Warlow Carotid endarterectomy for asymptomatic carotid stenosis BMJ, November 28, 1998; 317(7171): 1468 - 1468. [Full Text]

				L. T. Smurawska, B. Bowyer, D. Rowed, R. Maggisano, P. Oh, and J. W. Norris Changing Practice and Costs of Carotid Endarterectomy in Toronto, Canada Stroke, October 1, 1998; 29(10): 2014 - 2017. [Abstract] [Full Text] [PDF]

				T. S. Huber, K. G. Wheeler, J. K. Cuddeback, D. A. Dame, T. C. Flynn, and J. M. Seeger Effect of the Asymptomatic Carotid Atherosclerosis Study on Carotid Endarterectomy in Florida Stroke, June 1, 1998; 29(6): 1099 - 1105. [Abstract] [Full Text] [PDF]

				C J M Whitty, C L M Sudlow, and C P Warlow Investigating individual subjects and screening populations for asymptomatic carotid stenosis can be harmful J. Neurol. Neurosurg. Psychiatry, May 1, 1998; 64(5): 619 - 623. [Abstract] [Full Text] [PDF]

				L. B. Goldstein, G. P. Samsa, D. B. Matchar, and E. Z. Oddone Multicenter Review of Preoperative Risk Factors for Endarterectomy for Asymptomatic Carotid Artery Stenosis Stroke, April 1, 1998; 29(4): 750 - 753. [Abstract] [Full Text] [PDF]

				Managing carotid stenosis DTB, February 1, 1998; 36(2): 9 - 12. [Abstract] [Full Text] [PDF]

				S. Chaturvedi, P. N. Policherla, and L. Femino Cerebral Angiography Practices at US Teaching Hospitals : Implications for Carotid Endarterectomy Stroke, October 1, 1997; 28(10): 1895 - 1897. [Abstract] [Full Text]

				L. B. Goldstein, W. S. Moore, J. T. Robertson, and S. Chaturvedi Complication Rates for Carotid Endarterectomy : A Call to Action Stroke, May 1, 1997; 28(5): 889 - 890. [Full Text]

				J. H. Wong, J. M. Findlay, and M. E. Suarez-Almazor Regional Performance of Carotid Endarterectomy : Appropriateness, Outcomes, and Risk Factors for Complications Stroke, May 1, 1997; 28(5): 891 - 898. [Abstract] [Full Text]

				P.M. Rothwell, J. Slattery, and C.P. Warlow A Systematic Review of the Risks of Stroke and Death Due to Endarterectomy for Symptomatic Carotid Stenosis Stroke, February 1, 1996; 27(2): 260 - 265. [Abstract] [Full Text]

This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Rothwell, P.M. Articles by Warlow, C.P. Search for Related Content PubMed PubMed Citation Articles by Rothwell, P.M. Articles by Warlow, C.P.