Impact of Carotid Artery Stenosis on Quality of Life: A Systematic Review

  • Ahmed AberEmail author
  • Aoife Howard
  • Helen Buckley Woods
  • Georgina Jones
  • Jonathan Michaels
Systematic Review



The aim of this study was to identify themes that determine health-related quality of life (HRQoL) in patients with carotid artery stenosis and identify the patient-reported outcome measures (PROMs) that best cover the identified themes.


A systematic review of the main six databases from inception to September 2018 was undertaken to identify primary qualitative studies reporting on the HRQoL of patients with carotid artery stenosis. The quality of studies was assessed using the Critical Appraisal Skills Programme (CASP) criteria. Findings from the included studies were analysed using framework analysis methodology. The identified themes were mapped against the items/domains from the PROMs used previously in patients with carotid artery stenosis.


The systematic review identified four papers that fulfilled the inclusion criteria. The included papers reported the views of 62 patients with symptomatic carotid artery stenosis; 24 of the patients were awaiting assessment for intervention, 26 had carotid endarterectomy, and 12 were turned down for intervention and received best medical therapy. The overall quality of the included studies was good based on CASP criteria. Framework analysis identified 16 themes that were divided into five main domains: anxiety, impact on personal roles and activities, effect on independence, psychological impact, and symptoms. The best-fit generic and disease-specific PROMs were the Medical Outcomes Study 36-Item Short Form (SF-36®) and the Carotid Stenosis Specific Outcome Measure (CSSOM), respectively. None of the PROMs covered all the themes identified in the qualitative systematic review.


The findings from the review identified the important themes that affect patients with carotid stenosis disease. The current generic and disease-specific PROMs do not cover all themes that impact the HRQoL of patients suffering with this disease. The proposed themes can be used to develop a new disease-specific PROM to measure HRQoL.


Author Contributions

Ahmed Aber contributed to the analysis and interpretation of data, drafting of the manuscript, and critical revision. Aoife Howard contributed to the analysis and interpretation of data and drafting of the manuscript. Helen Buckley Woods performed the searches for the systematic review and helped in drafting of the manuscript. Georgina Jones contributed to the study conception and design, analysis and interpretation of data, and drafting of the manuscript. Jonathan Michaels contributed to the study conception and critical revision.

Compliance with Ethical Standards


This study was funded by the United Kingdom National Institute for Health Research (NIHR) under the Programme Grants for Applied Research programme (RP-PG-1210-12009). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.

Conflict of interest

Ahmed Aber, Aoife Howard, Helen Buckley Woods, Georgina Jones, and Jonathan Michaels have no conflicts of interest directly relevant to the content of this article.

Supplementary material

40271_2018_337_MOESM1_ESM.docx (14 kb)
Supplementary material 1 (DOCX 14 kb)


  1. 1.
    Luengo-Fernandez R, Gray AM, Bull L, Welch S, Cuthbertson F, Rothwell PM. Quality of life after TIA and stroke: ten-year results of the Oxford Vascular Study. Neurology. 2013;81(18):1588–95.CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    British Health Foundation, Heart Matters. Focus on: stroke and carotid artery disease. 2016. Available at: Accessed 30 Apr 2018.
  3. 3.
    Barnett HJ, Taylor DW, Eliasziw M, Fox AJ, Ferguson GG, Haynes RB, et al. Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med. 1998;339(20):1415–25.CrossRefPubMedGoogle Scholar
  4. 4.
    European Carotid Surgery Trialists’ Collaborative Group. Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST). Lancet. 1998;351(9113):1379–87.CrossRefGoogle Scholar
  5. 5.
    Halliday A, Mansfield A, Marro J, Peto C, Peto R, Potter J, et al. Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomised controlled trial. Lancet. 2004;363(9420):1491–502.CrossRefPubMedGoogle Scholar
  6. 6.
    Halliday A, Harrison M, Hayter E, Kong X, Mansfield A, Marro J, et al. 10-year stroke prevention after successful carotid endarterectomy for asymptomatic stenosis (ACST-1): a multicentre randomised trial. Lancet. 2010;376:1074–84.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Ederle J, Dobson J, Featherstone RL, Bonati LH, Worp HB, Borst GJ, et al. Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): an interim analysis of a randomised controlled trial. Lancet. 2010;375:985–97.CrossRefPubMedGoogle Scholar
  8. 8.
    Yadav JS, Wholey MH, Kuntz RE, Fayad P, Katzen BT, Mishkel GJ, et al. Protected carotid-artery stenting versus endarterectomy in high-risk patients. N Engl J Med. 2004;351(15):1493–501.CrossRefPubMedGoogle Scholar
  9. 9.
    Brott TG, Hobson RW, Howard G, Roubin GS, Clark WM, Brooks W, et al. Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med. 2010;363(1):11–23.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Bonati LH, Dobson J, Algra A, Branchereau A, Chatellier G, Fraedrich G, et al. Short-term outcome after stenting versus endarterectomy for symptomatic carotid stenosis: a preplanned meta-analysis of individual patient data. Lancet. 2010;376(9746):1062–73.CrossRefPubMedGoogle Scholar
  11. 11.
    Stolker JM, Mahoney EM, Safley DM, Pomposelli FB, Yadav JS, Cohen DJ. Health-related quality of life following carotid stenting versus endarterectomy: results from the SAPPHIRE (Stenting and Angioplasty with Protection in Patients at HIgh Risk for Endarterectomy) trial. JACC Cardiovascular interventions. 2010;3:515–23.CrossRefPubMedGoogle Scholar
  12. 12.
    Chabowski M, Grzebien A, Ziomek A, Dorobisz K, Lesniak M, Janczak D. Quality of life after carotid endarterectomy—a review of the literature. Acta Neurol Belg. 2017;117(4):829–35.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Hsu LC, Chang FC, Teng MMH, Chern CM, Wong WJ. Impact of carotid stenting in dizzy patients with carotid stenosis. J Chin Med Assoc. 2014;77(8):403–8.CrossRefPubMedGoogle Scholar
  14. 14.
    Cohen DJS. Health-related quality of life after carotid stenting versus carotid endarterectomy: results from CREST (Carotid Revascularization Endarterectomy versus Stenting Trial). J Am Coll Cardiol. 2011;58(15):1557–65.CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Black N. Patient reported outcome measures could help transform healthcare. BMJ. 2013;346:f167.CrossRefPubMedGoogle Scholar
  16. 16.
    Department of Health. Liberating the NHS: transparency in outcomes—a framework for the NHS. 2010. Accessed 30 Apr 2018.
  17. 17.
    Essat M, Aber A, Phillips P, Poku E, Woods HB, Howard A, Palfreyman S, Kaltenthaler E, Jones G, Michaels J. Patient-reported outcome measures in carotid artery revascularization: systematic review and psychometric analysis. Ann Vasc Surg. 2018;50:275–83.CrossRefPubMedGoogle Scholar
  18. 18.
    Duncan R, Booth A, Woods HB, Essat M, Phillips P, Poku, E, Kaltenthaler E, Jones G, Michaels J. Understanding the experience and impact of living with a vascular condition from the patients’ perspective: qualitative evidence synthesis protocol. HEDS discussion paper. 2016.!/file/DP_16_05.pdf. Accessed 08 June 2017.
  19. 19.
    Grant MJ (2004) How does your searching grow? A survey of search preferences and the use of optimal search strategies in the identification of qualitative research. Health information and libraries journal. Health Info Libr J. 2004;21(1):21–32.Google Scholar
  20. 20.
    Critical Appraisal Skills Programme. 10 questions to help you make sense of qualitative research: CASP qualitative check list. 2006;1–6. Accessed 30 Apr 2018.
  21. 21.
    Carroll C, Booth A. Quality assessment of qualitative evidence for systematic review and synthesis: is it meaningful, and if so, how should it be performed? Res Synth Methods. 2015;6(2):149–54.CrossRefPubMedGoogle Scholar
  22. 22.
    Ritchie J, Spencer L. Qualitative data analysis for applied policy research. In: Bryman G, Burgess A, editors. Analysing qualitative data. 4th ed. London: Routledge; 2015. p. 169–91.Google Scholar
  23. 23.
    Farmer T, Robinson K, Elliott SJ, Eyles J. Developing and implementing a triangulation protocol for qualitative health research. Qual Health Res. 2006;16:377–94.CrossRefPubMedGoogle Scholar
  24. 24.
    O’Cathain A, Murphy E, Nicholl J. Three techniques for integrating data in mixed methods studies. BMJ. 2010;341:c4587.CrossRefPubMedGoogle Scholar
  25. 25.
    Gibson J. Use of qualitative research to analyze patient and clinician decision making in carotid endarterectomy. J Vasc Nurs. 2002;20(2):60–5.CrossRefPubMedGoogle Scholar
  26. 26.
    Hallin A, Bergqvist D, Fugl-Meyer K, Holmberg L. Areas of concern, quality of life and life satisfaction in patients with peripheral vascular disease. Eur J Vasc Endovasc Surg. 2002;24(3):255–63.CrossRefPubMedGoogle Scholar
  27. 27.
    Gibson J, Watkins C. People’s experiences of the impact of transient ischaemic attack and its consequences: qualitative study. J Adv Nurs. 2012;68(8):1707–15.CrossRefPubMedGoogle Scholar
  28. 28.
    Gibson J, Watkins C. The use of formal and informal knowledge sources in patients’ treatment decisions in secondary stroke prevention: qualitative study. Health Expect. 2013;16(3):e13–23.CrossRefPubMedGoogle Scholar
  29. 29.
    Ivanova P, Kikule I, Zvirgzdins V, et al. Quality of life assessment for asymptomatic high-grade carotid stenosis patients before and after carotid endarterectomy. Gazz Med Ital Arch Sci Med. 2015;174:33–42.Google Scholar
  30. 30.
    Bowling A. Measuring health: a review of quality of life measurement scales. 4th ed. Buckingham: Open University Press; 2017.Google Scholar

Copyright information

© Springer Nature Switzerland AG 2018

Authors and Affiliations

  1. 1.School of Health and Related ResearchUniversity of SheffieldSheffieldUK
  2. 2.Department of Psychology, School of Social SciencesLeeds Beckett UniversityLeedsUK

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