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Background and Purpose-The European Carotid Surgery Trial (ECST) and North American Symptomatic CarotidEndarterectomy Trial (NASCET) have shown that endarterectomy reduces the risk of stroke in certain patients with recently symptomatic carotid stenosis. However, they differed in the degree of stenosis above which surgery was reported to be effective. This disparity has led to inconsistent clinical recommendations but may have been due to differences between the trials in the methods of measurement of carotid stenosis and definitions of outcome events. Methods-To allow direct comparison of analyses from ECST and NASCET, we remeasured the prerandomization ECST carotid angiograms and redefined the outcome events the same way as in NASCET. Results-We randomized 3018 patients and followed them up for a mean of 73 months. Surgery reduced the 5-year risk of any stroke or surgical death by 5.7% (95% CI, 0 to 11.6) in patients with 50% to 69% stenosis (nϭ646, Pϭ0.05) and by 21.2% (95% CI, 12.9 to 29.4) in patients with 70% to 99% stenosis without "near occlusion" (nϭ429, PϽ0.0001). These benefits were maintained at the 10-year follow-up. However, surgery was of no benefit in patients (nϭ125) with near occlusion. The effect of surgery in this group was highly significantly different from that in patients with 70% to 99% stenosis without near occlusion (Pϭ0.002). Surgery was harmful in patients with Ͻ30% stenosis (nϭ1321, Pϭ0.007) and of no benefit in patients with 30% to 49% stenosis (nϭ478, Pϭ0.6). Conclusions-Results of the ECST and NASCET were consistent when analyzed in the same way. In ECST, surgery was highly beneficial for 70% to 99% stenosis and moderately beneficial for 50% to 69% stenosis. However, contrary to clinical recommendations and current practice, surgery was of little benefit in patients with carotid near occlusion.

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Background and Purpose-Early studies showed that carotid endarterectomy (CEA) carried a high risk if performed within days after a large ischemic stroke. Therefore, many surgeons delay CEA for 4 to 6 weeks after any stroke. To determine the effect of delay to CEA on operative risk and benefit, we pooled data from the North American Symptomatic Carotid Endarterectomy Trial and the European Carotid Surgery Trial. Methods-Risk of ipsilateral ischemic stroke in the medical group, operative risk of stroke and death, and overall benefit from surgery were determined in relation to the time from the last symptomatic event to randomization. Operative risk of stroke and death was also determined in relation to the time to surgery. Analyses were stratified by sex and type of presenting event. Results-The 30-day perioperative risk of stroke and death was unrelated to the time since the last symptomatic event and was not increased in patients operated Ͻ2 weeks after nondisabling stroke. In contrast, the risk of ipsilateral ischemic stroke in the medical group fell rapidly with time since event (PϽ0.001), as did the absolute benefit from surgery (Pϭ0.001). This decline in benefit with time was unrelated to the type of presenting event but was more pronounced in women than men (difference PϽ0.001). Benefit in women was confined to those randomized Ͻ2 weeks after their last event, irrespective of severity of stenosis. Conclusions-CEA can be performed safely within 2 weeks of nondisabling ischemic stroke. Benefit from endarterectomy declines rapidly with increasing delay, particularly in women.