Carotid endarterectomy for asymptomatic carotid stenosis

Better data, but the case is still not convincing

Papers p 1477

Eleven years ago, before any randomised trials were published, a BMJ editorial came down against endarterectomy for asymptomatic carotid stenosis.1 In 1995, based on what now would be regarded as a less than rigorous review of the trials then available, I thought surgery was still not worthwhile. Too many operations would have to be done to prevent one patient having a stroke.2 Today the BMJ publishes the first systematic review of the evidence (p 1477).3 Should the earlier conclusions be modified, and what should we do now?

The present review is far more rigorous: there was an extensive search strategy (which didn't reveal any previously unknown trials); only randomised controlled trials were included; publication bias was considered; sensible outcomes were defined, although some might want to see the outcome of stroke combined with all rather than just with surgical deaths; trial quality was taken into account; the relevant data were extracted independently by two people; appropriate sensitivity analyses were done; …