A Cochrane review [Abstract] 1 included 3 studies with a total of 6 343 subjects with a recent symptomatic carotid stenosis (i.e. transient ischaemic attack (TIA) or non-disabling stroke). The studies compared endarterectomy plus best medical management with best medical management alone. Individual patient data on 6 092 participants was pooled and analysed after reassessing the carotid angiograms and outcomes from all 3 studies, and redefining outcome events where necessary, to achieve comparability. All studies dealt with an elderly, predominantly male, population. The median time from randomisation to trial surgery was 6 days and the mean follow-up 65 months.
There were no statisticalyy significant differences between surgery and medical management alone in 5-year risk of any stroke or operative death among subjects with less than 30% stenosis (RR 1.25, 95% CI 0.99 to 1.56; 2 studies, n=1 746), and among participants with 30% to 49% stenosis (RR 0.97, 95% CI 0.79 to 1.19; 2 studies, n=1 429). Surgery decreased 5-year risk of any stroke or operative death in participants with 50% to 69% stenosis (RR 0.77, 95% CI 0.63 to 0.94; 3 studies, n=1 549), and was highly beneficial in participants with 70% to 99% stenosis without near-occlusion (RR 0.53, 95% CI 0.42 to 0.67; 3 studies, n=1 095). In participants with near-occlusion, there was no statistically significant difference (RR 0.95, 95% CI 0.59 to 1.53; 2 studies, n=271). Benefit from surgery was greatest in men, patients aged 75 years or over, and patients randomised within 2 weeks after their last ischaemic event and fell rapidly with increasing delay.
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