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65 Benefit from carotid endarterectomy (CEA) depends on the  degree of symptomatic stenosis, but is also likely to be influenced by  other clinical and angiographic characteristics. However, individual  trials have been too small to allow reliable subgroup analysis. We  therefore studied pooled individual patient data from the European  Carotid Surgery Trial, the North American Symptomatic Carotid  Endarterectomy Trial and the Veterans Administration trial #309. We  determined the effect of CEA in 11 predefined subgroups: age (&lt;65,  65–74, 75+), sex, type of presenting event (cerebral vs ocular; TIA vs  stroke; lacunar vs non-lacunar), side of presenting event, months since  last event (&lt;1, 2–3, 4+), diabetes, plaque surface irregularity,  near-occlusion, and contralateral carotid occlusion. There were  statistically significant interactions between the risk of ipsilateral  ischaemic stroke in the medical group and 8 of the 11  subgroup variables. In the surgery group, there were interactions  between the operative risk of stroke and death and 6 subgroup  variables. We therefore assessed heterogeneity of overall treatment  effect (any ipsilateral ischaemic stroke and surgical stroke/death) in  these subgroups. There was clinically and statistically significant  heterogeneity within 5 subgroups: benefit from surgery increased with  age, was greater in men than women; decreased with time since  presenting event; was greater after stroke than TIA, and was absent in  cases of near-occlusion. For example, in patients with 50–69%  stenosis, the 5 yr absolute risk reduction was 10% (95% CI =  3–10, P=0.0005) in men and -3% (95% CI = -8 - 2, P=0.8) in  women (overall interaction, P=0.003). There were also important  differences in the effect of surgery for lacunar and non-lacunar  stroke. Patients who are most likely to benefit from CEA cannot be  identified using the degree of symptomatic carotid stenosis alone.  Several other clinical and angiographic characteristics influence the  efficacy of surgery. Optimal selection of patients will require a  risk-modelling approach using multiple baseline  characteristics.

stroke

A pooled analysis of individual patient data from trials of endarterectomy for symptomatic carotid stenosis: efficacy of surgery in important subgroups