Revisiting the appropriateness of carotid endarterectomy.
OBJECTIVE
In the 1980s, carotid endarterectomy was controversial because proof of efficacy was lacking, complication rates were high, and one third of cases were reported to be inappropriate. Since publication of several randomized controlled trials (RCTs), rates of carotid endarterectomy have doubled nationwide. This study assesses the appropriateness and use of carotid endarterectomy since publication of the RCTs.


METHODS
Using the literature, we developed a list of 1557 mutually exclusive indications for carotid endarterectomy and asked a panel of national experts to rate the appropriateness of each indication using the RAND methodology. We used these ratings to assess appropriateness in a sample of 2124 patients who underwent the procedure in 1997 to 1998 in 6 hospitals. We also analyzed the reasons for the procedure and rates of death, stroke, and myocardial infarction within 30 days of surgery.


RESULTS
Overall, 84.9% of operations were done for appropriate reasons, 4.5% for uncertain reasons, and 10.6% for inappropriate reasons. Among procedures considered inappropriate, the most common reasons were high comorbidity (46.6%) and minimal stenosis (27.1%). Overall, 72.5% were asymptomatic, 17.4% had a carotid transient ischemic attack, and 10.1% had a stroke. The 30-day rate of death or stroke was 5.47% for symptomatic patients and 2.26% for asymptomatic patients. Among patients having combined carotid and coronary artery bypass graft surgery, the rate was 10.32%. The complication rate in asymptomatic patients with high comorbidity was 5.56%.


CONCLUSIONS
Since the RCTs, rates of overuse appear to have fallen considerably, although they are still significant. A major shift has occurred toward operating on asymptomatic patients. Although overall complication rates were low, rates among asymptomatic patients with high comorbidity exceeded recommended thresholds.
Halm
Ethan A
EA
MPH, Department of Health Policy and Medicine, Box 1077, Mount Sinai School of Medicine, One Gustave L. Levy Place, New York, NY 10029, USA. ethan.halm@mountsinai.org
Chassin
Mark R
MR
Tuhrim
Stanley
S
Hollier
Larry H
LH
Popp
A John
AJ
Ascher
Enrico
E
Dardik
Herbert
H
Faust
Glenn
G
Riles
Thomas S
TS
D000368:Aged; D000369:Aged, 80 and over; D016893:Carotid Stenosis / Q000601:surgery; D015331:Cohort Studies; D015897:Comorbidity; D000075202:Contraindications; D001026:Coronary Artery Bypass / Q000009:adverse effects / Q000706:statistics & numerical data; D016894:Endarterectomy, Carotid / Q000009:adverse effects / Q000401:mortality / Q000706:statistics & numerical data*; D005260:Female; D006300:Health Services Misuse / Q000706:statistics & numerical data*; D006801:Humans; D007431:Intraoperative Complications; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D017063:Outcome Assessment, Health Care / Q000706:statistics & numerical data*; D018579:Patient Selection; D011183:Postoperative Complications; D016032:Randomized Controlled Trials as Topic / Q000706:statistics & numerical data; D018570:Risk Assessment; D013503:Surgery Department, Hospital / Q000592:standards / Q000706:statistics & numerical data; D014600:Utilization Review