Stroke: female sex, older age and hypertension increased the risk of stroke or death from carotid endarterectomy.

Clinical bottom line (level 2a)

  1. Patients who were undergoing a carotid endarterectomy were at increased risk of stroke or death if they were female, aged >74 years, had hypertension, had peripheral vascular disease, had occlusion of contralateral internal carotid artery, had stenosis of distal ipsilateral internal carotid artery or stenosis of ipsilateral external carotid artery.
  2. Patients who were undergoing carotid endarterectomy were at decreased risk of stroke or death if they had monocular ischaemia alone.
Rothwell et al: British Medical Journal 1997; 315: 1571-1517
Expires November 2002

The study

Systematic review of retrospective or prospective studies; case series or cohorts of
  • Patients: carotid endarterectomy
  • Intervention: presence of risk factors compared with absence of risk factors
  • Outcome: operative risk of stroke or death


    • Articles found in ?language using MEDLINE and Cochrane Collaboration's stroke database, dates not given (search terms: carotid endarterectomy and carotid surgery ) and Reference lists of all papers identified were searched. Unpublished data from the European carotid surgery trial. No hand searching.

    Selection criteria: As above plus, endarterectomy performed for symptomatic stenosis, asymptomatic stenosis or a combination of the two, but not explicitly for acute stroke; operative risks defined per operation rather than per patient; operative risk stratified according to one or more clinical or angiographic characteristics assessed before surgery; no evidence of a systematic policy for patients with different characteristics to be operated on by different surgeons or at different institutions.
    Appraisal criteria: not detailed in text
    Articles excluded if: data reported overlapped with those of a subsequent study

    37 studies were included, with a total of 7295 patients.
    There was no significant heterogeneity between studies in the odds of stroke or death.

    The evidence

    Patient expected event rate for stroke or death: 4.4%
    risk factor for
    stroke or death     		adjusted OR
    (95% CI)
    monocular vs cerebral transient ischaemic attack 0.49
    (0.37 to 0.66)
    female vs male 1.44
    (1.14 to 1.83)
    age (>74 vs <75 years) 1.36
    (1.09 to 1.71)
    hypertension 1.82
    (1.37 to 2.41)
    peripheral vascular disease 2.19
    (1.40 to 3.60)
    occlusion of contralateral internal carotid artery 1.91
    (1.35 to 2.69)
    stenosis of distal ipsilateral internal carotid artery 1.56
    (1.03 to 2.36)
    stenosis of ipsilateral external carotid artery 1.61
    (1.05 to 2.47)

    Comments

    1. One single risk factor over-rides all, that is: do you know the stroke rate of your surgical team ?

    Citation

    1. Rothwell PM, Slattery J, Warlow CP: Clinical and angiographic predictors of stroke and death from carotid endarterectomy: systematic review. British Medical Journal 1997; 315: 1571-1517
    Contributor: Clare Wotton and Bob Phillips, November 1999
    Reviewer: Martin Mueller

    Clinical Question.
    Patient carotid endarterectomy
    Intervention or Exposure presence of risk factors
    Comparison absence of risk factors
    Outcome operative stroke or death