Rerkasem Kittipan, Rothwell Peter M
Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand, 50200.
Cochrane Database Syst Rev. 2011 Apr 13(4):CD001081. doi: 10.1002/14651858.CD001081.pub2.
Severe narrowing (stenosis) of the carotid artery is an important cause of stroke. Surgical treatment (carotid endarterectomy) may reduce the risk of stroke, but carries a risk of operative complications.
To determine the balance of benefit versus risk of endarterectomy plus best medical management compared with best medical management alone in patients with a recent symptomatic carotid stenosis (i.e. transient ischaemic attack (TIA) or non-disabling stroke).
We searched the Cochrane Stroke Group Trials Register (July 2010), MEDLINE (1966 to March 2010), EMBASE (1990 to March 2010) and three other databases, and handsearched relevant journals and reference lists.
Randomised controlled trials.
Two review authors independently selected studies and extracted the data.
We included three trials. As the trials differed in the methods of measurement of carotid stenosis and in the definition of stroke, we did a pooled analysis of individual patient data on 6092 patients (35,000 patient years of follow-up) after reassessment of the carotid angiograms and outcomes from all three trials using the primary electronic data files and redefined outcome events where necessary to achieve comparability.On re-analysis, there were no statistically significant differences between the trials in the risks of any of the main outcomes in either of the treatment groups or in the effects of surgery. Surgery increased the five-year risk of ipsilateral ischaemic stroke in patients with less than 30% stenosis (N = 1746, absolute risk reduction (ARR) -2.2%, P = 0.05), had no significant effect in patients with 30% to 49% stenosis (N = 1429, ARR 3.2%, P = 0.6), was of marginal benefit in patients with 50% to 69% stenosis (N = 1549, ARR 4.6%, P = 0.04), and was highly beneficial in patients with 70% to 99% stenosis without near-occlusion (N = 1095, ARR 16.0%, P < 0.001). However, there was no evidence of benefit (N = 262, ARR -1.7%, P = 0.9) in patients with near-occlusions.Benefit from surgery was greatest in men, patients aged 75 years or over, and patients randomised within two weeks after their last ischaemic event and fell rapidly with increasing delay.
AUTHORS' CONCLUSIONS: Endarterectomy is of some benefit for 50% to 69% symptomatic stenosis and highly beneficial for 70% to 99% stenosis without near-occlusion. Benefit in patients with carotid near-occlusion is marginal in the short-term and uncertain in the long-term. These results are generalisable only to surgically-fit patients operated on by surgeons with low complication rates (less than 7% risk of stroke and death). Benefit from endarterectomy depends not only on the degree of carotid stenosis, but also on several other factors, including the delay to surgery after the presenting event.
颈动脉严重狭窄（狭窄）是中风的一个重要原因。手术治疗（颈动脉内膜切除术）可能会降低中风风险，但存在手术并发症的风险。
确定近期有症状性颈动脉狭窄（即短暂性脑缺血发作（TIA）或非致残性中风）患者，与单纯最佳药物治疗相比，内膜切除术加最佳药物治疗的获益与风险平衡。
我们检索了Cochrane中风小组试验注册库（2010年7月）、MEDLINE（1966年至2010年3月）、EMBASE（1990年至2010年3月）以及其他三个数据库，并手工检索了相关期刊和参考文献列表。
随机对照试验。
两名综述作者独立选择研究并提取数据。
我们纳入了三项试验。由于试验在颈动脉狭窄的测量方法和中风的定义上存在差异，我们在使用原始电子数据文件重新评估所有三项试验的颈动脉血管造影和结果后，对6092例患者（35000患者年的随访）的个体患者数据进行了汇总分析，并在必要时重新定义结局事件以实现可比性。重新分析后，两个治疗组中任何主要结局的风险以及手术效果在试验之间均无统计学显著差异。手术增加了狭窄程度小于30%患者同侧缺血性中风的五年风险（N = 1746，绝对风险降低（ARR）-2.2%，P = 0.05），对狭窄程度为30%至49%的患者无显著影响（N = 1429，ARR 3.2%，P = 0.6），对狭窄程度为50%至69%的患者有边际获益（N = 1549，ARR 4.6%，P = 0.04），对狭窄程度为70%至99%且无近乎闭塞的患者非常有益（N = 1095，ARR 16.0%，P < 0.001）。然而，对于近乎闭塞的患者没有获益证据（N = 262，ARR -1.7%，P = 0.9）。手术获益在男性、75岁及以上患者以及在最后一次缺血事件后两周内随机分组的患者中最大，并且随着延迟时间的增加而迅速下降。
内膜切除术对50%至69%的症状性狭窄有一定益处，对70%至99%且无近乎闭塞的狭窄非常有益。颈动脉近乎闭塞患者的获益在短期内是边际的，长期来看是不确定的。这些结果仅适用于由并发症发生率低（中风和死亡风险低于7%）的外科医生进行手术的适合手术的患者。内膜切除术的获益不仅取决于颈动脉狭窄程度，还取决于其他几个因素，包括发病事件后手术的延迟时间。
