Carotid endarterectomy death

The benefit of carotid endarterectomy for prevention of recurrent stroke has been studied previously in major trials.25,26 A recent meta-analysis has been completed that has combined these clinical trials to evaluate 6,092 patients.27 Carotid endarterectomy has been shown to be beneficial for preventing ipsilateral stroke in patients with symptomatic carotid artery stenosis of 70% or greater and is recommended in these patients. In patients with symptomatic stenosis of 50% to 69%, a moderate reduction in risk is seen in clinical trials. In all patients with stenosis of 50% to 69% and a recent stroke, carotid endarterectomy is appropriate. In other patients, surgical risk factors and surgeon skill should be considered prior to surgery. The patient should have, at a minimum, a life expectancy of 5 years, and the surgical risk of stroke and/or death should be less than 6%. Carotid endarterectomy is not beneficial for symptomatic carotid stenosis less than 50% and should not be considered in these patients. 

Table 18.2. The relationship between aspirin dose and the risk of stroke and death within 30 days of carotid endarterectomy in a non-randomized comparison within the North American Symptomatic Carotid Endarterectomy Trial (Barnett et al. 1998) and in a subsequent randomized controlled trial (Taylor et al. 1999)...

Carotid endarterectomy is associated with a variety of potential complications (Naylor and Ruckley 1996 Bond et al. 2002c) (Box 25.1). The most important of these are stroke and death. 

Bond R, Rerkasem K, Shearman CP et al. (2004c). Time trends in the published risks of stroke and death due to endarterectomy for symptomatic carotid stenosis. Cerebrovascular Diseases 18 37-46 Bossema ER, Brand N, Moll EL et al. (2005). Perioperative microembolism is not associated with cognitive outcome three months after carotid endarterectomy. European Journal of Vascular Endovascular Surgery 29 262-268... 

A systematic comparison of the risk of stroke and death due to carotid endarterectomy for symptomatic and asymptomatic stenosis. Stroke 27 266-269... 

Table 27.2. A systematic review of the studies reporting the operative risks of stroke or death in carotid endarterectomy according to the nature of the presenting event and stratified according to year of publication ...

Rothwell PM, Slattery J, Warlow CP (1997). Clinical and angiographic predictors of stroke and death from carotid endarterectomy systematic review. British Medical Journal 315 1571-1577... 

Fig. 28.2. The overall results of a meta-analysis of the operative risk of death (a) and stroke and death (b) from all studies published between 1990 and 2000 inclusive that reported risks from carotid endarterectomy for asymptomatic stenosis (Bond et ai. 2003a) compared with the same risks in the ACAS Trial (Executive Committee for the Asymptomatic Carotid Atherosclerosis Study 1995). Studies in the analysis of risk of stroke and death are...

Fig. 14.2. An external validation of the model detailed in Table 14.2 for the five-year risk of stroke on medical treatment in an independent randomized trial of endarterectomy versus medical treatment for symptomatic carotid stenosis (Rothwell et ai. 2005). Predicted risk of stroke on medical treatment is plotted against the observed risk of stroke in patients randomized to medical treatment in the trial (squares) and against the observed operative risk of stroke and death in patients randomized to surgical treatment (diamonds). Groups are quintiles of predicted risk.

Fig. 27.4. Absolute risk reduction (ARR) with surgery in the five-year risk of ipsilateral carotid territory ischemic stroke and any stroke or death within 30 days after trial surgery according to predefined subgroup variables in an analysis of pooled data from the two largest randomized trials of endarterectomy versus medical treatment for recently symptomatic carotid stenosis (Derived form Rothwell et ai. 2004b), Cl, confidence interval.

Fig, 28.3. The effect of endarterectomy for asymptomatic carotid stenosis on the risk of any stroke and operative death by sex (Rothwell 2004) in the /ksymptomatic Carotid Surgery Trial (ACST Halliday ef al. 2004) and the AC/ S Trial (Executive Committee for the Asymptomatic Carotid Atherosclerosis Study 1995). Cl, confidence interval. 

The ACAS reported a statistically borderline sex-treatment effect interaction, with no benefit from endarterectomy in women (Executive Committee for the Asymptomatic Carotid Atherosclerosis Study 1995). The same trend was seen in ACST (Halliday et al. 2004). A meta-analysis of the effect of endarterectomy on the five-year risk of any stroke and perioperative death in ACAS and ACST (Rothwell 2004) (Fig. 28.3) showed that benefit from surgery was greater in men than in women (pooled interaction, p = 0.01), and that it remained uncertain whether there is any worthwhile benefit in women at five years of follow-up, although some benefit may accrue with longer follow-up in ACST. 

Data regarding the role of CAS in low-surgical-risk patients with asymptomatic CAS are limited. The Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) lead-in registry has reported data for investigators during the roll-in phase (51). The 30-day rate of stroke and death in the 960 asymptomatic patients was 4.0%, and if limited to only patients under the age of 80 years is 3.3%. The 30-day rate of death and major stroke in patients under the age of 80 years was 1.4%. 

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