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Asymptomatic Carotid Stenosis -- How Much Difference Does Surgery Make?

Several studies have shown that carotid endarterectomy improves the long-term prognosis of patients with symptomatic high-grade stenosis. This meta-analysis reviewed the evidence on the value of this procedure for asymptomatic carotid stenosis.

Five randomized trials involving 2,440 asymptomatic patients with carotid stenosis of 50 percent or more were analyzed. Over a period of three years, the risk for ipsilateral stroke plus perioperative stroke or death was 6.4 percent for medically treated patients and 4.4 percent for surgical patients, a significant difference. The risk for stroke in any location was also significantly reduced (9.2 percent for the medically treated patients and 7.4 percent for the surgical patients). However, surgical patients had a 2.4 percent risk for stroke or death in the 30 days after randomization, compared with 0.4 percent for the medically treated group.

Comment: It's now reasonably clear that surgery improves long-term prognosis in patients with asymptomatic carotid stenosis. However, the magnitude of this benefit is relatively small, and some patients will suffer significant complications of surgery early on. An accompanying editorial points out that 50 people would have to be operated on to prevent one stroke and that we need better ways of identifying which asymptomatic patients are at higher or lower stroke risk before recommending surgery.

— KI Marton

Published in Journal Watch General Medicine January 8, 1999

Citation(s):

Benavente O et al. Carotid endarterectomy for asymptomatic carotid stenosis: A meta-analysis. BMJ 1998 Nov 28 317 1477-1480.

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Warlow C. Carotid endarterectomy for asymptomatic carotid stenosis: Better data, but the case is still not convincing. BMJ 1998 Nov 28 317 1468-1468.

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• Medline abstract (Free)