Document Detail


Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators.
MedLine Citation:
PMID:  9811916     Owner:  NLM     Status:  MEDLINE    
Abstract/OtherAbstract:
BACKGROUND: Previous studies have shown that carotid endarterectomy in patients with symptomatic severe carotid stenosis (defined as stenosis of 70 to 99 percent of the luminal diameter) is beneficial up to two years after the procedure. In this clinical trial, we assessed the benefit of carotid endarterectomy in patients with symptomatic moderate stenosis, defined as stenosis of less than 70 percent. We also studied the durability of the benefit of endarterectomy in patients with severe stenosis over eight years of follow-up. METHODS: Patients who had moderate carotid stenosis and transient ischemic attacks or nondisabling strokes on the same side as the stenosis (ipsilateral) within 180 days before study entry were stratified according to the degree of stenosis (50 to 69 percent or <50 percent) and randomly assigned either to undergo carotid endarterectomy (1108 patients) or to receive medical care alone (1118 patients). The average follow-up was five years, and complete data on outcome events were available for 99.7 percent of the patients. The primary outcome event was any fatal or nonfatal stroke ipsilateral to the stenosis for which the patient underwent randomization. RESULTS: Among patients with stenosis of 50 to 69 percent, the five-year rate of any ipsilateral stroke (failure rate) was 15.7 percent among patients treated surgically and 22.2 percent among those treated medically (P=0.045); to prevent one ipsilateral stroke during the five-year period, 15 patients would have to be treated with carotid endarterectomy. Among patients with less than 50 percent stenosis, the failure rate was not significantly lower in the group treated with endarterectomy (14.9 percent) than in the medically treated group (18.7 percent, P=0.16). Among the patients with severe stenosis who underwent endarterectomy, the 30-day rate of death or disabling ipsilateral stroke persisting at 90 days was 2.1 percent; this rate increased to only 6.7 percent at 8 years. Benefit was greatest among men, patients with recent stroke as the qualifying event, and patients with hemispheric symptoms. CONCLUSIONS: Endarterectomy in patients with symptomatic moderate carotid stenosis of 50 to 69 percent yielded only a moderate reduction in the risk of stroke. Decisions about treatment for patients in this category must take into account recognized risk factors, and exceptional surgical skill is obligatory if carotid endarterectomy is to be performed. Patients with stenosis of less than 50 percent did not benefit from surgery. Patients with severe stenosis (> or =70 percent) had a durable benefit from endarterectomy at eight years of follow-up.
Authors:
H J Barnett; D W Taylor; M Eliasziw; A J Fox; G G Ferguson; R B Haynes; R N Rankin; G P Clagett; V C Hachinski; D L Sackett; K E Thorpe; H E Meldrum; J D Spence
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Publication Detail:
Type:  Clinical Trial; Journal Article; Multicenter Study; Randomized Controlled Trial; Research Support, U.S. Gov't, P.H.S.    
Journal Detail:
Title:  The New England journal of medicine     Volume:  339     ISSN:  0028-4793     ISO Abbreviation:  N. Engl. J. Med.     Publication Date:  1998 Nov 
Date Detail:
Created Date:  1998-11-18     Completed Date:  1998-11-18     Revised Date:  2007-11-14    
Medline Journal Info:
Nlm Unique ID:  0255562     Medline TA:  N Engl J Med     Country:  UNITED STATES    
Other Details:
Languages:  eng     Pagination:  1415-25     Citation Subset:  AIM; IM    
Affiliation:
John P. Robarts Research Institute, London, ON, Canada.
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MeSH Terms
Descriptor/Qualifier:
Aged
Carotid Stenosis / classification,  complications,  pathology,  surgery*
Cerebrovascular Disorders / etiology,  mortality,  prevention & control*
Disease-Free Survival
Endarterectomy, Carotid*
Female
Follow-Up Studies
Humans
Ischemic Attack, Transient / etiology
Male
Middle Aged
Proportional Hazards Models
Risk Factors
Severity of Illness Index
Treatment Failure
Grant Support
ID/Acronym/Agency:
R01-NS-24456/NS/NINDS NIH HHS
Comments/Corrections
Comment In:
N Engl J Med. 1998 Nov 12;339(20):1468-71   [PMID:  9811924 ]
N Engl J Med. 1999 Apr 15;340(15):1209; author reply 1210-1   [PMID:  10206845 ]
N Engl J Med. 1999 Apr 15;340(15):1209-10; author reply 1211   [PMID:  10206846 ]
N Engl J Med. 1999 Apr 15;340(15):1210; author reply 1211-2   [PMID:  10206847 ]
ACP J Club. 1999 Mar-Apr;130(2):33

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine


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