Rothwell PM, Eliasziw M, Gutnikov SA, et al: Endarterectomy for symptomatic carotid stenosis in relation to clinical subgroups and timing of surgery. Lancet 2004;363(9413):915-24.
Carotid endarterectomy reduces the risk of stroke in patients with recently symptomatic stenosis. Based on data from recent trials, surgery is harmful in patients with less than 30% stenosis, of no benefit in those with 30% to 49% stenosis, of some benefit in those with 50% to 60% stenosis, and highly beneficial for those with higher than 70% stenosis without near-occlusion.
To determine if factors other than the amount of stenosis affect risks and benefits of carotid endarterectomy, pooled data was analyzed from 5,893 patients with 33,000 patient years of follow-up. Sex, age, and time from the last symptomatic event to randomization all significantly influenced the effectiveness of surgery. Male patients older than 75 years of age, as well as those randomized within 2 weeks after their last ischemia event benefited the most. The number of patients who needed to undergo surgery to prevent one ipsilateral stroke in 5 years was five for those randomized within 2 weeks after their last ischemic event for patients with 50% or greater stenosis. This was compared to 125 for patients randomized after more than 12 weeks.
Ideally, carotid endarterectomy should be performed within 2 weeks of the patient's last symptoms. These results do not justify withholding carotid endarterectomy for patients older than 75 years of age who are found to be medically fit to undergo surgery.