Carotid Endarterectomy: A Challenge for Scientific Medicine

  • H. J. M. Barnett


Carotid endarterectomy (CE) was introduced very shortly after cerebral angiography identified the extracranial portion of the carotid artery as a common site responsible for stroke-threatening transient ischemic attacks (TIA). On the face of it, it was, and to many remains, as logical a surgical activity as the removal of an acoustic neuroma or the clipping of a saccular intracranial aneurysm. Why, then, has the procedure fallen afoul of universal acceptance? The reasons are several:
  1. 1.

    In the case of a ruptured aneurysm, the mortality, let alone the morbidity, from a recurrent hemorrhage is close to 50%. The survivors have almost an equal chance of being left with a serious disability. The TIA patient has at least a 90% chance of going through each successive year after the initial event(s) without a serious outcome.

  2. 2.

    If a stroke does occur, there is at least a 30% chance of its being in another arterial territory from that of the artery that caused the presenting symptoms.



Carotid Endarterectomy Acoustic Neuroma Transient Cerebral Ischemia North American Symptomatic Carotid Endarterectomy Trial Asymptomatic Carotid Stenosis 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Bisch L, Lee KI, Mark E. Major Causes of Death, Canada 1989. Chronic Diseases in Canada, Health and Welfare Canada, 1989; pp 22–24.Google Scholar
  2. 2.
    MacMahon S, Peto R, Cutler J, et al. Part 1: Prolonged differences in blood pressure: prospective observational studies corrected for the regression dilution bias. Lancet. 1990;335:765–774.PubMedCrossRefGoogle Scholar
  3. 3.
    Collins R, Peto R, MacMahon HP, et al. Part 2: Short-term reductions in blood pressure: overview of randomized drug trials in their epidemiological context. Lancet. 1990;335:827–838.PubMedCrossRefGoogle Scholar
  4. 4.
    Walker WJ. Change in per capita consumption in the United States 1963–1980. N Engl J Med. 1983;308: 649–651.PubMedCrossRefGoogle Scholar
  5. 5.
    Antiplatelet Trialists’ Collaboration. Secondary prevention of vascular disease by prolonged antiplatelet treatment. Br Med J. 1988;296:320–331.Google Scholar
  6. 6.
    Gent M, Blakely JA, Easton JD, et al. The Canadian-American Ticlopidine Study (CATS) in thromboembolic stroke. Lancet. 1989;1215–1220.Google Scholar
  7. 7.
    Hass WK, Easton JD, Adams HP, et al. A randomized trial comparing Ticlopidine hydrochloride with Aspirin for the prevention of stroke in high-risk patients. New Engl J Med. 1989;321:501–507.PubMedCrossRefGoogle Scholar
  8. 8.
    Dyken ML, Pokras R. The performance of endarterectomy for disease of the extracranial arteries of the head. Stroke. 1984;15:948–950.PubMedCrossRefGoogle Scholar
  9. 9.
    Dyken ML. Carotid endarterectomy studies: a glimmering of science (editorial). Stroke. 1986;17:355–358.PubMedCrossRefGoogle Scholar
  10. 10.
    Ernest FIV, Forbes G, Sandok BA, et al. Complications of cerebral angiography: Prospective assessment of risk. AJNR. 1983;4:1191–1197.Google Scholar
  11. 11.
    Dion JE, Gates PC, Fox AJ, et al. Clinical events following neuroangiography: a prospective study. Stroke. 1987;18:997–1004.PubMedCrossRefGoogle Scholar
  12. 12.
    Fisher B, Bauer M, Margolese R, et al. Five-year results of a randomized clinical trial comparing total mastectomy and segmental mastectomy with or without radiation in the treatment of breast cancer. N Engl J Med. 1985;312:665–673.PubMedCrossRefGoogle Scholar
  13. 13.
    The EC/IC Bypass Study Group. Failure of extracranial-intracranial arterial bypass to reduce the risk of ischemic stroke. New Engl J Med. 1985; 393:1191–1200.Google Scholar
  14. 14.
    Fields WS, Maslenikov V, Meyer JS, et al. Joint study of extracranial arterial occlusion. JAMA. 1970;211:1993–2003.PubMedCrossRefGoogle Scholar
  15. 15.
    Shaw DA, Venables GS, Cartlidge NEF, et al. Carotid endarterectomy in patients with transient cerebral ischemia. J Neurol Sci. 1984;64:45–53.PubMedCrossRefGoogle Scholar
  16. 16.
    Chambers BR, Norris JW. Outcome in patients with asymptomatic neck bruits. N Engl J Med. 1986; 315:860–865.PubMedCrossRefGoogle Scholar
  17. 17.
    Barnett HJM, Plum F, Walton JN. Carotid endarterectomy-an expression of concern. Stroke. 1984; 15:941–943.PubMedCrossRefGoogle Scholar
  18. 18.
    Caplan LR. Carotid-artery disease (editorial). N Engl J Med. 1987;315:886–888.CrossRefGoogle Scholar
  19. 19.
    Warlow CP. Carotid endarterectomy: does it work? Stroke. 1984;15:1068–1076.PubMedCrossRefGoogle Scholar
  20. 20.
    Trobe JD. Carotid endarterectomy: who needs it? Ophthalmology. 1987;94:725–730.PubMedGoogle Scholar
  21. 21.
    Pokras R, Dyken ML. Dramatic changes in the performance of endarterectomy for diseases of the extracranial arteries of the head. Stroke. 1988;19: 1289–1290.PubMedCrossRefGoogle Scholar
  22. 22.
    News programs 20/20, Nightline. ABC Television, New York, New York, February 6, 1986.Google Scholar
  23. 23.
    Califano JA Jr. Billions blown on health. New York Times, 12 April 1989.Google Scholar
  24. 24.
    Ludtyke M. Physician, inform thyself. New York Times Magazine, 16 April 1989.Google Scholar
  25. 25.
    Rich S. Califano calls U.S. health bill at least $125 billion too high. Washington Post. 9 May 1988.Google Scholar
  26. 26.
    Surtees L. Doubts on operation make it hard to find patients for research. Toronto Globe and Mail, 17 June 1988.Google Scholar
  27. 27.
    Katz S. Do you really need surgery? Chatelaine. August 1989;65–67.Google Scholar
  28. 28.
    Beebe HG, Clagett GP, DeWeese JA, et al. Assessing risk associated with carotid endarterectomy: a statement for health professionals by an ad hoc committee on carotid surgery standards of the Stroke Council, American Heart Association. Circulation. 1979; 2:314–315.Google Scholar
  29. 29.
    Feussner JR, Matchar DB. When and how to study the carotid arteries. Ann Intern Med. 1988;109:805–818.PubMedCrossRefGoogle Scholar
  30. 30.
    Callow AD, Caplan LR, Correll JW, et al. Carotid endarterectomy-what is its current status? Am J Med. 1988;85:835–838.PubMedCrossRefGoogle Scholar
  31. 31.
    Interim assessment: carotid endarterectomy: report of the American Academy of Neurology, Therapeutics and Technology Assessment Subcommittee. Neurology. 1990;40: 682–683.Google Scholar
  32. 32.
    Committee of Health Care Issues. American Neurological Association. Does carotid endarterectomy decrease stroke and death in patients with transient ischemic attacks? Ann Neurol. 1987;22:72–76.Google Scholar
  33. 33.
    Winslow CM, Solomon DH, Chassin MR, et al. The appropriateness of carotid endarterectomy. N Engl J Med. 1988;318:721–727.PubMedCrossRefGoogle Scholar
  34. 34.
    Lord RSA. Surgery of Occlusive Cerebrovascular Disease. St. Louis, MO: C.V. Mosby Company; 1986.Google Scholar
  35. 35.
    Hertzer NR. Presidential address. Carotid endarterectomy — a crisis in confidence. J. Vasc. Surg. 1988; 7:611–619.PubMedGoogle Scholar
  36. 36.
    Thompson JE. Don’t throw out the baby with the bath water. A perspective on carotid endarterectomy. J Vasc Surg. 1986;4:543–545.PubMedGoogle Scholar
  37. 37.
    Goldring S, Zervas N, Langfitt T. The extracranial-intracranial bypass study: a report of the committee appointed by the American Association of Neurological Surgeons to examine the study. N Engl J Med. 1987;316:817–820.PubMedCrossRefGoogle Scholar
  38. 38.
    Sundt I. Was the international randomized trial of an extracranial-intracranial arterial bypass representative of the population at risk? N Engl J Med. 1987; 316:814–816.PubMedCrossRefGoogle Scholar
  39. 39.
    Relman A. The extracranial-intracranial arterial bypass study—what have we learned? N Engl J Med. 1987;316:809–810.PubMedCrossRefGoogle Scholar
  40. 40.
    Barnett, HJM, Sackett D, Taylor DW, et al. Are the results of the extracranial-intracranial bypass trial generalizable? N Engl J Med. 1987;316:820–824.PubMedCrossRefGoogle Scholar
  41. 41.
    Chalmers TC, Meier P, Plum F. The EC/IC bypass study (letter to the editor). N Engl J Med. 1987; 317:1030–1031.CrossRefGoogle Scholar
  42. 42.
    Hobson RW II, Towne J. Carotid endarterectomy for asymptomatic carotid stenosis (editorial). Stroke. 1989;20:575–576.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 1991

Authors and Affiliations

  • H. J. M. Barnett

There are no affiliations available

Personalised recommendations