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CAROTID ENDARTERECTOMY IS CONFIRMED BENEFICIAL IN HIGH-GRADE STENOSIS.

The value of carotid endarterectomy was established in a randomized study only recently, when the European Carotid Surgery Trial showed a clear benefit in patients with stenosis of 70 percent or greater (see Journal Watch accession number 910607001). Now a large North American trial has reached exactly the same conclusion.

The randomized trial involved 50 centers and 659 patients with 70 percent or greater stenosis who had suffered a hemispheric or retinal transient ischemic attack (TIA) or nondisabling stroke within the previous 120 days. The patients received either carotid surgery or medical therapy alone; all received aggressive medical care, including antiplatelet therapy, and were carefully followed. After two years, the surgical and medical groups had markedly different projected cumulative risks for ipsilateral stroke (9 percent vs. 26 percent) and major or fatal ipsilateral stroke (3 percent vs. 13 percent), with no indication that the benefits from surgery would attenuate. Subgroups with progressively greater degrees of stenosis had progressively greater benefits from surgery. The perioperative risk of major stroke or death was 2.1 percent.

Provided surgical teams are as skilled as these, carotid endarterectomy is definitely indicated in patients with TIAs or minor strokes and high-grade stenosis who otherwise qualify for surgery. The European and North American trials are continuing to examine the benefits of surgery in patients with moderate stenosis (30 to 69 percent).

— ALK

Published in Journal Watch General Medicine August 23, 1991

Citation(s):

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 Aug 15 325 445-453.

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