Are we still performing inappropriate carotid endarterectomy?
OBJECTIVE
the 1998 ECST final report suggests that the decision to operate on patients with greater than 70% symptomatic stenosis should be based on a statistical model incorporating age, sex and degree of stenosis. The aim of this study was to identify patients operated on the basis of the 1991 reports who would not now be offered surgery according to the 1998 ECST recommendations and to determine the surgical morbidity and mortality arising from these <<<<inappropriate>>>> CEAs.


METHODS
interrogation of a prospectively gathered database of all CEAs performed for symptomatic stenosis between 1st January 1994 and 1st May 1998. CEAs were classified as <<<<beneficial>>>>, <<<<uncertain>>>> or <<<<hazardous>>>> according to the 1998 ECST recommendations.


RESULTS
there were 154 males and 72 females (median age (range) was 67 (39-85) and 65 (38-81), respectively). In males 101 (66%) of CEAs were <<<<beneficial>>>>, 51 (33%) were <<<<uncertain>>>> and only two (1%) were <<<<hazardous>>>>. In women, the corresponding proportions were 13 (18%), 45 (63%) and 14 (19%), respectively. The combined peri-operative major stroke (Rankin 3-5) and death rate was 1.8% (4 patients). Of these, three, one and zero patients were in the <<<<beneficial>>>>, <<<<uncertain>>>> and <<<<hazardous>>>> groups.


CONCLUSIONS
strict adherence to the 1998 ECST recommendations would reduce by 50% the number of CEAs currently performed in this vascular unit and, in general, would restrict CEA to a higher risk group. The validity of the ECST model requires further evaluation.
Brittenden
J
J
Vascular Surgery Unit, University Department of Clinical and Surgical Sciences, Edinburgh, EH3 9YW, Scotland, U.K.
Bradbury
A W
AW
D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D016893:Carotid Stenosis / Q000145:classification / Q000175:diagnosis / Q000601:surgery*; D016894:Endarterectomy, Carotid / Q000009:adverse effects / Q000401:mortality / Q000706:statistics & numerical data*; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D008297:Male; D008875:Middle Aged; D015233:Models, Statistical; D018579:Patient Selection; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011446:Prospective Studies; D015203:Reproducibility of Results; D012606:Scotland / Q000453:epidemiology; D012720:Severity of Illness Index; D012737:Sex Factors; D020521:Stroke / Q000209:etiology; D016019:Survival Analysis; D019564:Unnecessary Procedures / Q000009:adverse effects / Q000401:mortality / Q000706:statistics & numerical data