CLINICAL AND ANGIOGRAPHIC PREDICTORS OF STROKE AND DEATH FROM CAROTIDENDARTERECTOMY - SYSTEMATIC REVIEW

Objective: To identify risk factors for operative stroke and death fro m carotid endarterectomy. Design: Systematic review of all studies pub lished since 1980 which related risk of stroke and death to various pr eoperative clinical and angiographic characteristics, including unpubl ished data on 1729 patients from the European carotid surgery trial Ma in outcome measure: Operative risk of stroke and death. Results: Thirt y sh published studies fulfilled our criteria. The effect of 14 potent ial risk factors was examined. The odds of stroke and death were decre ased in patients with ocular ischaemia alone (amaurosis fugax or retin al artery occlusion) compared with those with cerebral transient ischa emic attack or stroke (seven studies; odds ratio 0.49; 95% confidence interval 0.37 to 0.66; P < 0.00001). The odds were increased in women (seven studies; 1.41; 1.14 to 1.83; P < 0.005), subjects aged greater than or equal to 75 years (10 studies; 1.36; 1.09 to 1.71; P < 0.01), and with systolic blood pressure > 180 mm Hg (four studies; 1.82; 1.37 to 2.41; P < 0.0001), peripheral vascular disease (one study; 2.19; 1 .40 to 3.60; P < 0.0005), occlusion of the contralateral internal caro tid artery (14 studies; 1.91; 1.35 to 2.69; P < 0.0001), stenosis of t he ipsilateral internal carotid siphon (five studies; 1.56; 1.03 to 2. 36; P = 0.02), and stenosis of the ipsilateral external carotid artery (one study; 1.61; 1.05 to 2.47; P = 0.03). Operative risk was not sig nificantly related to presentation with cerebral transient ischaemic a ttack versus stroke, diabetes, angina, recent myocardial infarction, c urrent cigarette smoking, or plaque surface irregularity at angiograph y. Multiple regression analysis of data from the European carotid surg ery trial identified cerebral versus ocular events at presentation, fe male sex, systolic hypertension, and peripheral vascular disease as in dependent risk factors. Conclusions: The risk of stroke and death from carotid endarterectomy is related to several clinical and angiographi c characteristics. These observations may help clinicians to estimate operative risks for individual patients and will also facilitate more meaningful comparison of the operative risks of different surgeons or at different institutions by allowing some adjustment for differences in case mix.