Carotid endarterectomy for asymptomatic carotid stenosis: a meta-analysis

Objective To assess the value of carotid endarterectomy for prevention of s troke in patients with asymptomatic carotid stenosis. Design Systematic review and meta-analysis of randomised controlled trials in patients with asymptomatic carotid stenosis in which subjects were alloc ated to carotid endarterectomy or to medical treatment alone. Subjects Five trials enrolled 2440 patients with stenosis greater than or e qual to 50%. Main outcome measures Stroke ipsilateral to the stenosis, all strokes, and perioperative complications (stroke or death). Results In patients who underwent carotid endarterectomy (n = 1215) there w as a significant reduction in the odds of ipsilateral stroke plus periopera tive stroke or death (odds ratio 0.62; 95% confidence interval 0.44 to 0.86 ), corresponding to a 2% absolute risk reduction over about 3.1 years. The prevalence of stroke in any location was also reduced (0.68; 0.51 to 0.9) i n patients undergoing carotid endarterectomy. During the immediate postoper ative period there was an increased prevalence of stroke or death among suc h patients (4.51; 2.36 to 8.64). Conclusion Carotid endarterectomy in patients with asymptomatic carotid ste nosis unequivocally reduces the incidence of ipsilateral stroke, though the absolute benefit is relatively small. Given the modest benefit of surgery for unselected patients with asymptomatic carotid artery stenosis carotid e ndarterectomy cannot be routinely recommended for these patients pending re liable identification of high risk subgroups, and medical management is a s ensible alternative for most patients.