{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,27]],"date-time":"2026-10-27T13:19:57Z","timestamp":1793107197668,"version":"4.5.0"},"reference-count":58,"publisher":"BMJ","issue":"7122","license":[{"start":{"date-parts":[[1997,12,13]],"date-time":"1997-12-13T00:00:00Z","timestamp":881971200000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/www.bmj.com\/company\/legal-information\/terms-conditions\/legal-information\/tdm-licencepolicy"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["BMJ"],"accepted":{"date-parts":[[1997,7,9]]},"published-print":{"date-parts":[[1997,12,13]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:p>\n                    <jats:bold>Objective:<\/jats:bold>\n                    To identify risk factors for operative stroke and death from carotid endarterectomy.\n                  <\/jats:p>\n                  <jats:p>\n                    <jats:bold>Design:<\/jats:bold>\n                    Systematic review of all studies published since 1980 which related risk of stroke and death to various preoperative clinical and angiographic characteristics, including unpublished data on 1729 patients from the European carotid surgery trial.\n                  <\/jats:p>\n                  <jats:p>\n                    <jats:bold>Main outcome measure:<\/jats:bold>\n                    Operative risk of stroke and death.\n                  <\/jats:p>\n                  <jats:p>\n                    <jats:bold>Results:<\/jats:bold>\n                    Thirty six published studies fulfilled our criteria. The effect of 14 potential risk factors was examined. The odds of stroke and death were decreased in patients with ocular ischaemia alone (amaurosis fugax or retinal artery occlusion) compared with those with cerebral transient ischaemic attack or stroke (seven studies; odds ratio 0.49; 95% confidence interval 0.37 to 0.66; P&lt;0.00001). The odds were increased in women (seven studies; 1.44; 1.14 to 1.83; P&lt;0.005), subjects aged \u226575 years (10 studies; 1.36; 1.09 to 1.71; P&lt;0.01), and with systolic blood pressure &gt;180 mm Hg (four studies; 1.82; 1.37 to 2.41; P&lt;0.0001), peripheral vascular disease (one study; 2.19; 1.40 to 3.60; P&lt;0.0005), occlusion of the contralateral internal carotid artery (14 studies; 1.91; 1.35 to 2.69; P&lt;0.0001), stenosis of the ipsilateral internal carotid siphon (five studies; 1.56; 1.03 to 2.36; P=0.02), and stenosis of the ipsilateral external carotid artery (one study; 1.61; 1.05 to 2.47; P=0.03). Operative risk was not significantly related to presentation with cerebral transient ischaemic attack versus stroke, diabetes, angina, recent myocardial infarction, current cigarette smoking, or plaque surface irregularity at angiography. Multiple regression analysis of data from the European carotid surgery trial identified cerebral versus ocular events at presentation, female sex, systolic hypertension, and peripheral vascular disease as independent risk factors.\n                  <\/jats:p>\n                  <jats:p>\n                    <jats:bold>Conclusions:<\/jats:bold>\n                    The risk of stroke and death from carotid endarterectomy is related to several clinical and angiographic characteristics. These observations may help clinicians to estimate operative risks for individual patients and will also facilitate more meaningful comparison of the operative risks of different surgeons or at different institutions by allowing some adjustment for differences in case mix.\n                  <\/jats:p>\n                  <jats:p>\n                    <jats:boxed-text position=\"float\">\n                      <jats:sec>\n                        <jats:title>Key messages<\/jats:title>\n                        <jats:list list-type=\"bullet\">\n                          <jats:list-item>\n                            <jats:p>Although carotid endarterectomy has been shown to reduce the risk of stroke in selected patients, there is about a 5% operative risk of stroke and death<\/jats:p>\n                          <\/jats:list-item>\n                          <jats:list-item>\n                            <jats:p>The cost effectiveness of the operation is limited by the associated morbidity and mortality<\/jats:p>\n                          <\/jats:list-item>\n                          <jats:list-item>\n                            <jats:p>The risk of stroke and death from carotid endarterectomy is higher in women than in men<\/jats:p>\n                          <\/jats:list-item>\n                          <jats:list-item>\n                            <jats:p>Other clinical characteristics associated with an increased risk include cerebral as opposed to ocular transient ischaemic attack, age over 75 years, systolic hypertension, and peripheral vascular disease<\/jats:p>\n                          <\/jats:list-item>\n                          <jats:list-item>\n                            <jats:p>Angiographic characteristics associated with an increased operative risk include occlusion of the contralateral internal carotid artery and stenosis of the ipsilateral carotid siphon or external carotid artery<\/jats:p>\n                          <\/jats:list-item>\n                        <\/jats:list>\n                      <\/jats:sec>\n                    <\/jats:boxed-text>\n                  <\/jats:p>","DOI":"10.1136\/bmj.315.7122.1571","type":"journal-article","created":{"date-parts":[[2011,10,27]],"date-time":"2011-10-27T19:50:09Z","timestamp":1319745009000},"page":"1571-1577","source":"Crossref","is-referenced-by-count":269,"title":["Clinical and angiographic predictors of stroke and death from carotid endarterectomy: systematic review"],"prefix":"10.1136","volume":"315","author":[{"given":"P M","family":"Rothwell","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"J","family":"Slattery","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"C P","family":"Warlow","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[1997,12,13]]},"reference":[{"key":"2025122509295900000_315.7122.1571.1","doi-asserted-by":"crossref","first-page":"209","DOI":"10.1016\/S0140-6736(95)90220-1","article-title":"Risk of stroke in the distribution of an asymptomatic carotid artery.","volume":"345","year":"1995","journal-title":"Lancet"},{"key":"2025122509295900000_315.7122.1571.2","doi-asserted-by":"publisher","DOI":"10.1056\/NEJM199301283280401"},{"key":"2025122509295900000_315.7122.1571.3","doi-asserted-by":"publisher","DOI":"10.1001\/jama.1995.03520420037035"},{"key":"2025122509295900000_315.7122.1571.4","unstructured":"Rothwell PM Slattery J Warlow CP on behalf of the European Carotid Surgery Trial .Can we identify the patients with most to gain and least to lose from endarterectomy? Cerebrovasc Dis 1994;suppl 1:260."},{"key":"2025122509295900000_315.7122.1571.5","doi-asserted-by":"publisher","DOI":"10.1136\/jnnp.55.8.640"},{"key":"2025122509295900000_315.7122.1571.6","doi-asserted-by":"crossref","first-page":"527","DOI":"10.1161\/01.STR.24.4.527","article-title":"Predictors of major vascular events in patients with a transient ischemic attack or nondisabling stroke.","volume":"24","year":"1993","journal-title":"Stroke"},{"key":"2025122509295900000_315.7122.1571.7","doi-asserted-by":"crossref","first-page":"260","DOI":"10.1161\/01.STR.27.2.260","article-title":"A systematic review of the risks of stroke and death due to carotid endarterectomy for symptomatic stenosis.","volume":"27","author":"Rothwell","year":"1996","journal-title":"Stroke"},{"key":"2025122509295900000_315.7122.1571.8","doi-asserted-by":"publisher","DOI":"10.1016\/0140-6736(91)92916-P"},{"key":"2025122509295900000_315.7122.1571.9","doi-asserted-by":"crossref","first-page":"1591","DOI":"10.1016\/S0140-6736(96)91077-6","article-title":"MRC European carotid surgery trial. The effectiveness of carotid endarterectomy in patients with 30-69% symptomatic carotid stenosis.","volume":"347","year":"1996","journal-title":"Lancet"},{"key":"2025122509295900000_315.7122.1571.10","unstructured":"Cochrane database of systematic reviews. London: BMJ Publishing Group,1995."},{"key":"2025122509295900000_315.7122.1571.11","doi-asserted-by":"crossref","first-page":"445","DOI":"10.1056\/NEJM199108153250701","article-title":"Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis.","volume":"325","year":"1991","journal-title":"N Engl J Med"},{"key":"2025122509295900000_315.7122.1571.12","doi-asserted-by":"publisher","DOI":"10.1016\/S0033-0620(85)80003-7"},{"key":"2025122509295900000_315.7122.1571.13","first-page":"557","article-title":"Carotid endarterectomy in the community hospital: a continuing controversy.","volume":"27","author":"Cafferata","year":"1986","journal-title":"J Cardiovasc Surg"},{"key":"2025122509295900000_315.7122.1571.14","doi-asserted-by":"crossref","first-page":"370","DOI":"10.1161\/01.STR.17.3.370","article-title":"Multicenter retrospective review of results and complications of carotid endarterectomy in 1981.","volume":"17","author":"Fode","year":"1986","journal-title":"Stroke"},{"key":"2025122509295900000_315.7122.1571.15","doi-asserted-by":"crossref","first-page":"333","DOI":"10.1016\/0741-5214(87)90003-6","article-title":"Late results after carotid endarterectomy for amaurosis fugax.","volume":"6","author":"Bernstein","year":"1987","journal-title":"J Vasc Surg"},{"key":"2025122509295900000_315.7122.1571.16","doi-asserted-by":"crossref","first-page":"329","DOI":"10.1161\/01.STR.20.3.329","article-title":"Prospective analysis of carotid endarterectomy and silent cerebral infarction in 97 patients.","volume":"20","author":"Sise","year":"1989","journal-title":"Stroke"},{"key":"2025122509295900000_315.7122.1571.17","doi-asserted-by":"crossref","first-page":"232","DOI":"10.1016\/0741-5214(88)90141-3","article-title":"Carotid endarterectomy with local anesthesia: results and advantages.","volume":"7","author":"Hafner","year":"1988","journal-title":"J Vasc Surg"},{"key":"2025122509295900000_315.7122.1571.18","doi-asserted-by":"crossref","first-page":"1323","DOI":"10.1161\/01.STR.19.11.1323","article-title":"Carotid endarterectomy. Clinical results in a community-based teaching hospital.","volume":"19","author":"Friedmann","year":"1988","journal-title":"Stroke"},{"key":"2025122509295900000_315.7122.1571.19","doi-asserted-by":"crossref","first-page":"178","DOI":"10.1016\/0741-5214(89)90352-2","article-title":"Risk factors in a community experience with carotid endarterectomy.","volume":"10","author":"Kirshner","year":"1989","journal-title":"J Vasc Surg"},{"key":"2025122509295900000_315.7122.1571.20","doi-asserted-by":"crossref","first-page":"257","DOI":"10.3109\/02688699109005185","article-title":"Neurosurgical experience with carotid endarterectomy: a 12 year study.","volume":"5","author":"Allcutt","year":"1991","journal-title":"Br J 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digital subtraction angiography after two hundred and sixty-two operations.","volume":"92","author":"Hertzer","year":"1982","journal-title":"Surgery"},{"key":"2025122509295900000_315.7122.1571.37","doi-asserted-by":"crossref","first-page":"59","DOI":"10.1097\/00000658-198207000-00013","article-title":"Carotid endarterectomy under regional (conductive) anesthesia.","volume":"196","author":"Peitzman","year":"1982","journal-title":"Ann Surg"},{"key":"2025122509295900000_315.7122.1571.38","first-page":"839","article-title":"Does contralateral carotid occlusion influence neurologic fate of carotid endarterectomy?","volume":"96","author":"Sachs","year":"1984","journal-title":"Surgery"},{"key":"2025122509295900000_315.7122.1571.39","doi-asserted-by":"publisher","DOI":"10.1067\/mva.1984.avs0010409"},{"key":"2025122509295900000_315.7122.1571.40","doi-asserted-by":"crossref","first-page":"447","DOI":"10.1016\/0741-5214(88)90109-7","article-title":"Carotid endarterectomy in patients with territorial transient ischemic attacks.","volume":"8","author":"Nunn","year":"1988","journal-title":"J Vasc Surg"},{"key":"2025122509295900000_315.7122.1571.41","doi-asserted-by":"publisher","DOI":"10.1067\/mva.1990.20249"},{"key":"2025122509295900000_315.7122.1571.42","doi-asserted-by":"crossref","first-page":"665","DOI":"10.1161\/01.STR.24.5.665","article-title":"Carotid endarterectomy with transcranial Doppler and electroencephalographic monitoring: a prospective study in 130 operations.","volume":"24","author":"Jansen","year":"1993","journal-title":"Stroke"},{"key":"2025122509295900000_315.7122.1571.43","doi-asserted-by":"crossref","first-page":"1098","DOI":"10.1161\/01.STR.24.7.1098","article-title":"Risks and benefits of shunting in carotid endarterectomy.","volume":"24","author":"Sandmann","year":"1993","journal-title":"Stroke"},{"key":"2025122509295900000_315.7122.1571.44","first-page":"1058","article-title":"The effect of carotid siphon stenosis on stroke rate, death, and 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endarterectomy.","volume":"24","author":"McCrory","year":"1993","journal-title":"Stroke"},{"key":"2025122509295900000_315.7122.1571.48","doi-asserted-by":"crossref","first-page":"266","DOI":"10.1161\/01.STR.27.2.266","article-title":"A systematic comparison of the risks of stroke and death due to carotid endarterectomy for symptomatic and asymptomatic stenosis.","volume":"27","author":"Rothwell","year":"1996","journal-title":"Stroke"},{"key":"2025122509295900000_315.7122.1571.49","doi-asserted-by":"crossref","first-page":"246","DOI":"10.1001\/archneur.1995.00540270034016","article-title":"The risk of stroke in patients with first-ever retinal vs hemispheric transient ischemic attack and high-grade carotid stenosis.","volume":"52","author":"Streifler","year":"1995","journal-title":"Arch Neurol"},{"key":"2025122509295900000_315.7122.1571.50","first-page":"314","article-title":"Assessing risk associated with carotid endarterectomy. A statement for health professionals by an ad hoc committee on carotid surgery standards of the Stroke Council, American Heart Association.","volume":"20","author":"Beebe","year":"1989","journal-title":"Stroke"},{"key":"2025122509295900000_315.7122.1571.51","doi-asserted-by":"crossref","first-page":"188","DOI":"10.1161\/01.STR.26.1.188","article-title":"Guidelines for carotid endarterectomy.","volume":"26","year":"1995","journal-title":"Stroke"},{"key":"2025122509295900000_315.7122.1571.52","first-page":"1179","article-title":"Changing clinical characteristics of coronary surgery patients. 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