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64 Carotid endarterectomy (CEA) is beneficial for severe  symptomatic stenosis, but trial results for moderate stenosis have been  conflicting. This may be due to the differences between trials in the  method of measurement of carotid stenosis, differences in outcome  definitions, or chance. We used the same definitions of outcomes and  the same method of measurement of stenosis to pool individual patient  data on over 95% of patients ever randomised in trials of CEA for  symptomatic stenosis: European Carotid Surgery Trial (ECST); North  American Symptomatic Carotid Endarterectomy Trial; Veterans  Administration trial #309. The degree of stenosis was remeasured on the  3018 pre-randomisation ECST angiograms by the method used in the other  two trials. Remeasurements correlated well with the original  measurements (r=0.94, P&lt;0.00001). Data were merged on 6092 patients  with 1711 strokes and 1493 deaths during 35,000 patient years of  follow-up. Patients were categorised according to the degree of  symptomatic stenosis: &lt;30% (n=1755); 30–49% (n=1441); 50–69%  (n=1547); 70–99% (n = 1338); occlusion (n = 9); unknown  (n=2). Surgery was harmful in patients with &lt;30% stenosis, and was of  no benefit in patients with 30–49% stenosis. Surgery reduced the risk  ofany stroke or surgical death in patients with 50–69%  stenosis (NNT = 14, 95% CI = 8–30), and this was consistent  across the individual trials. Surgery was highly beneficial in patients  with 70–99% stenosis (NNT = 8, 95% CI = 5–12), but had no  effect on overall survival. Operative mortality was 1.1% (95% CI  = 0.9–1.4) and the operative risk of stroke and death was 7.0% (95%  CI = 6.2–8.0). In contrast to interpretations of the original  trial reports, by using the same outcome definitions and the same  method of measurement of stenosis we have demonstrated that the trial  results are entirely consistent. By combining all available trial data  we have determined the effect of surgery with greater precision. CEA  reduces the risk ofany stroke or death in patients with  50–99% carotid stenosis, although benefit is less than for 70–99%  stenosis.

Overall results of a pooled analysis of individual patient data from trials of endarterectomy for symptomatic carotid stenosis