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Hoots : Why is carotid endarterectomy not beneficial for symptomatic 100% internal carotid stenosis? According to this review article, for symptomatic internal carotid artery stenosis: [Carotid endarterectomy] was highly beneficial - freshhoot.com

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Why is carotid endarterectomy not beneficial for symptomatic 100% internal carotid stenosis?
According to this review article, for symptomatic internal carotid artery stenosis:

[Carotid endarterectomy] was highly beneficial in participants with 70% to 99% stenosis without near-occlusion (N = 1095, RR 0.47, 95%CI 0.25 to 0.88). However, there was no evidence of benefit (N = 271, RR 1.03, 95%CI 0.57 to 1.84) in participants with near-occlusions

Why is carotid endarterectomy beneficial for 70%-99%, but not 100% stenosis (unsure if this is the correct term)?
Source:
Orrapin S, Rerkasem K. Carotid endarterectomy for symptomatic carotid stenosis. Cochrane Database Syst Rev. 2017 Jun 7;6(6):CD001081. doi: 10.1002/14651858.CD001081.pub3. PMID: 28590505; PMCID: PMC6481587.


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I think this is probably due to selection bias, but I cannot find a source from someone in the field to reference.
Instead, to support this conclusion, note that in the review you reference, the people with near-occlusions overall have fewer negative outcomes than those with lesser occlusions.
People who are not already dead while having such a blockage clearly have enough collateral circulation to compensate for the near-occlusion. Something that is already blocked cannot become suddenly blocked in the future.
The review also mentions that these are all intent-to-treat analyses, and so it's not necessarily the case that those with near-occlusions did end up having surgery after all, despite being allocated to the non-surgery group. However, the lower (rather than higher) risk in this group seems to argue against that.


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