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Abstract
Objective: To systematically review temporal changes in perioperative safety of carotid endarterectomy (CEA) in asymptomatic individuals in trial and registry studies.
Methods: The MEDLINE and EMBASE databases were searched using the terms “carotid” and “endarterectomy” and “asymptomatic” from 1947 to August 23, 2014. Articles dealing with 50%–99% stenosis in asymptomatic individuals were included and low-volume studies were excluded. The primary endpoint was 30-day stroke or death and the secondary endpoint was 30-day all-cause mortality. Statistical analysis was performed using random-effects meta-regression for registry data and for trial data graphical interpretation alone was used.
Results: Six trials (n = 4,431 procedures) and 47 community registries (n = 204,622 procedures) reported data between 1983 and 2013. Registry data showed a significant decrease in postoperative stroke or death incidence over the period 1991–2010, equivalent to a 6% average proportional annual reduction (95% credible interval [CrI] 4%–7%; p < 0.001). Considering postoperative all-cause mortality, registry data showed a significant 5% average proportional annual reduction (95% CrI 3%–9%; p < 0.001). Trial data showed a similar visual trend.
Conclusions: CEA is safer than ever before and high-volume registry results closely mirror the results of trials. New benchmarks for CEA are a stroke or death risk of 1.2% and a mortality risk of 0.4%. This information will prove useful for quality improvement programs, for health care funders, and for those re-examining the long-term benefits of asymptomatic revascularization in future trials.
GLOSSARY
- ACAS=
- Asymptomatic Carotid Atherosclerosis Study;
- ACST-1=
- Asymptomatic Carotid Surgery Trial 1;
- CaRESS=
- Carotid Revascularization Using Endarterectomy or Stenting Systems;
- CEA=
- carotid endarterectomy;
- CREST=
- Carotid Revascularization Endarterectomy versus Stenting Trial;
- CrI=
- credible interval;
- GALA=
- General Anaesthesia Versus Local Anaesthesia for Carotid Surgery;
- OR=
- odds ratio;
- PrI=
- prediction interval
Footnotes
Go to Neurology.org for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.
Editorial, page 302
Supplemental data at Neurology.org
- Received May 6, 2014.
- Accepted in final form January 22, 2015.
- © 2015 American Academy of Neurology
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