Tamer Ammar, MD; Ken Uchino, MD, FAHA
Is immediate carotid endarterectomy (CEA) better than deferred CEA for long-term outcomes in patients with severe, asymptomatic carotid artery stenosis?
Randomized controlled trial (Asymptomatic Carotid Surgery Trial 1 [ACST-1]). Current Controlled Trials ISRCTN26156392.
Blinded (endpoint review committee).*
Median 9 years for survivors.
126 centers in 30 countries. Each center had a neurosurgeon or vascular surgeon and an independent neurologist or physician specializing in stroke.
3120 patients who had severe, unilateral or bilateral carotid artery stenosis (generally ≥ 60% reduction in diameter) that had not caused stroke, transient cerebral ischemia, or other neurologic symptoms in the past 6 months. Both physicians and patients had to be uncertain about the choice of immediate CEA or deferral of any CEA.
Immediate CEA (n = 1560) or indefinitely deferred carotid procedures (n = 1560).
Primary endpoints were nonperioperative stroke and a composite of perioperative mortality or morbidity (death or stroke at ≤ 30 d). Other outcomes included a composite endpoint of any stroke or perioperative mortality.
94% (intention-to-treat analysis) within 2 years of last scheduled clinic visit.
91% and 26% of patients in the immediate and deferred CEA groups, respectively, had CEA within 10 years; 36% of the 26% in the deferred group had ipsilateral stroke or transient cerebral ischemia before CEA. Perioperative stroke or death rates did not differ for immediate or deferred CEA (2.9% vs 3.6% of CEAs). At 10 years, immediate CEA reduced risk for nonperioperative stroke and any stroke or perioperative mortality more than deferred CEA (Table).
In severe, asymptomatic carotid artery stenosis, immediate endarterectomy reduced long-term risk for nonperioperative stroke and a composite of any stroke or perioperative mortality.
Immediate carotid endarterectomy (CEA) vs indefinitely deferred CEA in severe, asymptomatic carotid artery stenosis†
†Abbreviations defined in Glossary. RRR and CI for nonperioperative stroke calculated from data in article.
‡Information provided by author.
Ammar T, Uchino K. Immediate surgery reduced long-term risk for nonperioperative stroke in severe asymptomatic carotid artery stenosis. Ann Intern Med. ;154:JC2–7. doi: 10.7326/0003-4819-154-4-201102150-02007
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Published: Ann Intern Med. 2011;154(4):JC2-7.
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