(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
From the Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK.
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Abstract |
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 Top Abstract IntroductionMethods Results Discussion References |
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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
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Introduction |
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TopAbstractIntroductionMethods Results Discussion References |
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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.
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Methods |
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TopAbstractIntroductionMethods Results Discussion References |
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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.
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Results |
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TopAbstractIntroductionMethods Results Discussion References |
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Twenty-five studies11 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).
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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).
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Discussion |
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TopAbstractIntroductionMethods Results Discussion References |
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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 trials3 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.
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Selected Abbreviations and Acronyms |
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Acknowledgments |
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This study was funded by the United Kingdom Medical Research Council (Dr Rothwell and Mr Slattery).
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Footnotes |
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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.
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