Surgical Management of Extracranial Atherosclerosis: Indications and Timming

Abstract

Operative treatment of all types of occlusive cerebrovascular disease is undergoing an agonizing reappraisal of operative indications. Carotid endarterectomy is no exception. Optimal information on the natural history of carotid occlusive disease is obtained from population-based surveys in which an entire community can be under medical surveillance for a long period of time. In this way, a determination of stroke incidence and survival following transient ischemic attack can made. Such data from the population of Rochester, Minnesota have been obtained and analysed. This analysis shows that the probability of survival following first transient ischemic attack is 91% at 6 months, 88% at 1 year, and 50% between 7 and 8 years. Actuarial assessment of the probability of stroke among patients following first transient ischemic attacks shows an 8% probability of stroke at 1 month, 10% probability of stroke at 6 months, 13% probability of stroke at 1 year, and a 40% probability of stroke at 8 years. Thus, in order to improve upon this natural history by any operative treatment, the morbidity and mortality of each proposed treatment must be low. In a series of 1935 patients operated upon by our department from 1972 to 1984, the overall mortality was 1.3%, major morbidity 1%, and minor morbidity 1%. Using the Sundt grading schema, the combined morbidity/mortality was less than 1.0% in grade I, 1.8% in grade II, 4.0% in grade III, and 8.5% in grade IV. We believe carotid endarterectomy can be an effective operation for patients with symptomatic carotid stenosis [1].