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From the Stroke Program and Department of Neurology (Dr. Chaturvedi), Wayne State University; Department of Neurology (Dr. Bruno), Indiana University; University of Alberta (Dr. Feasby); Department of Neurology (Dr. Holloway), University of Rochester, NY; Department of Neurology (Dr. Benavente), University of Texas-San Antonio; Stroke Prevention Program (Dr. Cohen), Sunrise Hospital, Las Vegas, NV; Department of Neurology (Dr. Cote), McGill University; Department of Neurology (Dr. Hess), Medical College of Georgia; UCLA Stroke Center (Dr. Saver); Robarts Research Institute (Dr. Spence); Department of Neurology (Dr. Stern), University of Maryland; and Department of Neurology (Dr. Wilterdink), Brown University.
Address correspondence and reprint requests to American Academy of Neurology, 1080 Montreal Ave., St. Paul, MN 55116.
Objective: To assess the efficacy of carotid endarterectomy for stroke prevention in asymptomatic and symptomatic patients with internal carotid artery stenosis. Additional clinical scenarios, such as use of endarterectomy combined with cardiac surgery, are also reviewed.
Methods: The authors selected nine important clinical questions. A systematic search was performed for articles from 1990 (the year of the last statement) until 2001. Additional articles from 2002 through 2004 were included using prespecified criteria. Two reviewers also screened for other relevant articles from 2002 to 2004. Case reports, review articles, technical studies, and single surgeon case series were excluded.
Results: For several questions, high quality randomized clinical trials had been completed. Carotid endarterectomy reduces the stroke risk compared to medical therapy alone for patients with 70 to 99% symptomatic stenosis (16% absolute risk reduction at 5 years). There is a smaller benefit for patients with 50 to 69% symptomatic stenosis (absolute risk reduction 4.6% at 5 years). There is a small benefit for asymptomatic patients with 60 to 99% stenosis if the perioperative complication rate is low. Aspirin in a dose of 81 to 325 mg per day is preferred vs higher doses (650 to 1,300 mg per day) in patients undergoing endarterectomy.
Conclusions: Evidence supports carotid endarterectomy for severe (70 to 99%) symptomatic stenosis (Level A). Endarterectomy is moderately useful for symptomatic patients with 50 to 69% stenosis (Level B) and not indicated for symptomatic patients with <50% stenosis (Level A). For asymptomatic patients with 60 to 99% stenosis, the benefit/risk ratio is smaller compared to symptomatic patients and individual decisions must be made. Endarterectomy can reduce the future stroke rate if the perioperative stroke/death rate is kept low (<3%) (Level A). Low dose aspirin (81 to 325 mg) is preferred for patients before and after carotid endarterectomy to reduce the rate of stroke, myocardial infarction, and death (Level A).
Additional material related to this article can be found on the Neurology Web site. Go to www.neurology.org and scroll down the Table of Contents for the September 27 issue to find the title link for this article.
This guideline was approved by the Therapeutics and Technology Assessment Subcommittee on November 19, 2004; by the Practice Committee on April 13, 2005; and by the Board of Directors on June 26, 2005.
Disclosure: The authors report no conflicts of interest.
Received February 18, 2005. Accepted in final form June 15, 2005.
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