Benefit of carotid endarterectomy in patients

with symptomatic moderate or severe stenosis

RFS Journal Primer

Quick Summary
BOTTOM LINE

Compared to standard medical therapy for symptomatic carotid artery stenosis, patients with stenosis of
70-99% benefit significantly from carotid endarterectomy (CEA) to prevent ipsilateral stroke. Patients with
moderated stenosis of (50-69%) may benefit from CEA in preventing ipsilateral stroke and risk factors
should be considered. Patients with (< 50%) stenosis do not benefit from CEA compared to medical therapy.

MAJOR POINTS

CEA is durable procedure that provides significant benefit for patient with 70-99% carotid artery stenosis

CEA provides only modest benefit to patients with 50-69% stenosis

CEA provides no benefit compared to medical therapy in patients with < 50% stenosis

CRITICISM

The study did not include patients older than 80 years old.

Males benefited greater than females from CEA. Females may benefit less from CEA because of decreased
general overall stroke risk compare to males.

Degree of stenosis was measured with angiography and noninvasive measurement modalities may not be
equally applicable.

Study design
MULTICENTER, PARALLEL-GROUP, RANDOMIZED CONTROLLED TRIAL

N=2226
Randomized to CEA (N=1,108) or medical therapy (N= 1,118)

Time: 1987-1991

INCLUSION CRITERIA

Symptoms of focal cerebral ischemia ipsilateral to a intercal carotid artery

stenosis less than 70% within 180 days as shown on selective angiography
persisting less than 24 hours producing a nondisabling stroke (Rankin score <3)

EXCLUSION CRITERIA

Lack of angiographic visualization of the symptomatic artery

Intracranial stenosis that was more clinically significant than the cervical lesion

Estimated life expectancy to less than five years

Cerebral infarction that eliminated useful function in the affected arterial territory,
nonatherosclerotic carotid disease, cardiac lesions likely to cause cardioembolism, and a
history of ipsilateral endarterectomy.

Age > 80 years

Purpose

Previous studies demonstrated that patients with symptomatic carotid stenosis ( 70-99%)
benefit up to two years following carotid endarterectomy procedure.

Assess the benefit of CEA in patients with symptomatic moderate carotid stenosis (50-69%)
and mild stenosis (< 50%) at an average follow up of 5 years.

Assess the durability of CEA in patients with severe stenosis (70-99%) at eight years follow
up.

Intervention

Of the 2226 eligible patients with carotid stenosis of 70% or less, 1118 were
randomly assigned to the medical therapy group while the remaining 1108 were
randomly assigned to the surgical group.
Both groups were treated with aspirin, anti-hypertensives, and anti-lipids.
Patients in the surgical group underwent CEA in addition to the medical therapy.
Centers were required to demonstrate that their participating surgeons had a
perioperative rate of stroke and death of <6% in a minimum of 50 consecutive cases
accumulated over 2 years. In centers with >1 surgeon, the number of patients could
represent the aggregate experience of participating surgeons in the center, with a
minimum of 30 personal cases for any single surgeon.
Surgical technique was left to the discretion of the surgeon.
Neurologic assessment at entry, at 1, 3, 6, 9, and 12 months, and every 4 months for
underlying causes of all deaths and the territory, type, severity, and duration of
strokes.
Average follow up was 5 years for all patients.

Outcome

Outcome

For the primary outcome of ipsilateral stroke, five year failure rate for patients with a 50-69%
stenosis was 22.2% for those medically treated versus 15.7 % for those undergoing CEA
(P=0.045). The relative risk reduction was 6.5%, and NNT was 15 which is twice that for
patients with stenosis of 70 percent or more.

For the primary outcome of ipsilateral stroke , five year failure rate for patients with < 50%
stenosis was 18.7% for those medically treated and 14.4% surgically treated with CEA
(P=0.16). There was no significant difference between the surgically treated group versus the
medically treated group.

CEA provided durable benefit for patients with severe >70 % stenosis with 6.7% rate of death
or disabling ipsilateral stroke at 8 year follow-up.

Credits

SUMMARY BY:

Jeffrey J Farrell, M.D. , R2 PGY 3

Diagnostic Radiology
University Hospitals Case Medical Center/CWRU
Barnett HJ, et al. "Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis". The New England Journal
of Medicine. 1998. 339(20):1415-25.

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