Refining the indications for carotid endarterectomy in patients with symptomatic carotid stenosis: A systematic review

Objective: The purpose of this study was to summarize the existing literatu re on the efficacy of carotid endarterectomy in patients with ipsilateral s ymptomatic carotid stenosis. Methods: Database searching, relevance assessment, methodologic quality ass essments, and data extraction were all performed in duplicate with prespeci fied criteria. Results: Twenty-three publications were identified from the North American Symptomatic Carotid Endarterectomy Trial, the European Carotid Surgery Tria l, and the Veterans Affairs Cooperative Studies Program. Stenosis was repor ted as measured in the North American Symptomatic Carotid Endarterectomy Tr ial. In patients with >70% stenosis, carotid endarterectomy was associated with a pooled relative risk reduction of 48% (95% confidence interval [CI], 27% to 73%) and an absolute risk reduction of 6.7% (95% CI, 3.2% to 10%) f or the outcome of death or major disability from stroke. This translates in to a number needed to treat of 15 (95% CI, 10 to 31). For patients with 50% to 69% stenosis, the benefit of surgery was less and the confidence interv als were wider. A relative risk reduction of 27% (95% CI, 5% to 44%), an ab solute risk reduction of 4.7% (95% CI, 0.8% to 8.7%), and a number needed t o treat of 21 (95% CI, 11 to 125) were observed in this group. The patients with the lowest degrees of stenosis (<50%) were harmed by the intervention (number needed to harm, 45). Increasing degree of stenosis, increasing age , male sex, the presence of other medical risk factors, and the presence of hemispheric rather than retinal antecedent events were factors that increa sed the benefits from surgery. Conclusion: Carotid endarterectomy reduced death or major disability from s troke in patients with >50% symptomatic stenosis. To maximize the benefits of surgery, careful preoperative risk assessment and the maintenance of low rates of major perioperative complications are mandatory.