Carotid Endarterectomy: Indications and Techniques

Abstract

“The eventual definition of the precise role of surgery in the management of cerebral vascular insufficiency must await the outcome of further studies, but it may be safely said at this time that surgical measures have already demonstrated their effectiveness in many patients with stroke syndromes.” ¹ Jesse Thompson, a most distinguished carotid surgeon, wrote this in 1968. Nearly a quarter of a century had to pass before official accreditation was bestowed.² During this time, rejection of surgical therapy among many physicians ranged from simple withholding of acceptance to stifling opposition. Largely because of the conviction among most vascular and neurosurgeons, based on their personal experience, that carotid endarterectomy was a beneficial and durable procedure for the prevention of carotid territory stroke, the number of operations increased each year. Approximately 17,000 were performed in 1977 and over 100,000 in 1984 in the United States alone. From 1954 to 1990 the worldwide number of carotid endarterectomies was estimated as approximately one million. Although excellent results in terms of operative morbidity and mortality as well as duration of stroke prevention were published,^3–7 many reports were less salutary. This was particularly true in some series dealing with the asymptomatic carotid lesion with clearly unacceptably high rates of perioperative stroke and death.^8–15 Confusion as to the proper indications for and the true utility of carotid endarterectomy increased in the medical and lay communities, and the need for controlled randomized studies became apparent.^16–18