Carotid endarterectomy.
OBJECTIVE
To evaluate the usefulness of doing carotid endarterectomy in patients with symptomatic or asymptomatic carotid artery disease.


METHODS
Synthesis and summarization of data on the untreated course of cerebrovascular disease, and review of selected evidence and expert opinion on the risks and benefits of endarterectomy and medical therapy.


RESULTS
There is a large body of data related to the untreated course of cerebrovascular disease, the efficacy of aspirin in patients with transient ischemic attacks, and the comparative responsiveness to surgery of symptomatic patients with different presentations. Randomized trials in progress will increase the knowledge about the effects of aspirin in asymptomatic patients, the comparative efficacy of aspirin and endarterectomy in asymptomatic and symptomatic patients, and the factors that influence surgical risk. Clinicians and investigators wish to define a more limited and precise set of indications for carotid endarterectomy. In setting standards, attention has properly focussed on "maximum acceptable complication rates," native stroke risk, and surgical efficacy for patients with different clinical presentations. Illustrative, acceptable surgical mortality rates are less than 1%, and stroke-related morbidity is less than 3% for patients who have had a transient ischemic attack; surgical mortality and stroke-related morbidity are less than 2% for patients with asymptomatic carotid stenosis. Medical comorbidity and angiographic findings are important factors affecting specific recommendations.


CONCLUSIONS
Data from ongoing clinical trials will provide a more scientific foundation for recommendations about when to do carotid endarterectomy. Current evidence suggests that fewer endarterectomies should be done, and those on the basis of a more precise set of indications. Clinicians should consider the clinical presentation, the patient's comorbidity and native stroke risk, angiographic findings, and the experience of the surgical team.
Cebul
R D
RD
Case Western Reserve University, Cleveland Metropolitan General Hospital, Ohio.
Whisnant
J P
JP
D000925:Anticoagulants / Q000627:therapeutic use; D002340:Carotid Artery Diseases / Q000150:complications / Q000601:surgery*; D002561:Cerebrovascular Disorders / Q000209:etiology / Q000517:prevention & control* / Q000601:surgery; D004691:Endarterectomy / Q000009:adverse effects / Q000401:mortality; D006801:Humans; D002546:Ischemic Attack, Transient / Q000150:complications / Q000601:surgery; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use; D012008:Recurrence; D012307:Risk Factors
D000925:Anticoagulants; D010975:Platelet Aggregation Inhibitors