The risk and benefit of endarterectomy in women with symptomatic internal carotid artery disease

Background and Purpose-Perioperative risk and long-term benefit of carotid endarterectomy (CE) are not detailed in women with symptomatic internal carotid artery (ICA) stenosis. Our aim was to compare the efficacy of CE versus medical therapy in women and men with symptomatic ICA stenosis. Methods-Data were taken from the North American Symptomatic Carotid Endarterectomy Trial ( 873 women, 2012 men) and the ASA and Carotid Endarterectomy trial ( 335 women, 813 men). Results-The 30-day perioperative risk of death was higher in women than in men (2.3% versus 0.8%, P=0.002). Higher perioperative risk of stroke and death was also observed (7.6% versus 5.9%) but not statistically significant. With greater than or equal to70% stenosis, the 5-year absolute risk reduction (ARR) in stroke from CE was similar between women (15.1%) and men (17.3%). With 50% to 69% stenosis, CE was not beneficial in women (ARR=3.0%, P=0.94), contrary to men (ARR=10.0%, P=0.02). Medically treated women had low risk for stroke. A stroke prognosis instrument (SPI-II) assigned points to 7 factors that identified higher risk for medically treated women: 3 points for hemispheric (not retinal) event, history of diabetes, previous stroke; 2 for age older than 70 years, stroke (not transient ischemic attack); 1 for severe hypertension, history of myocardial infarction. CE was beneficial only for 29.0% of women with 50% to 69% stenosis who had the highest total score of 8 to 15 (ARR=8.9%). Conclusions-Women and men with greater than or equal to70% symptomatic stenosis had similar long-term benefit from CE, although the perioperative risks were higher for women. CE was not beneficial for women with 50% to 69% stenosis without other risk factors for stroke.