Carotid Endarterectomy—Why Are We Still Doing This Operation?

Abstract

The first report of surgical treatment for symptomatic carotid artery stenosis appeared in 1954. Surgeons quickly learned the technique for what appeared to be an intuitively logical operation. Between 1971 and 1985 carotid endarterectomy increased from 15,000 to 107,000 cases per day. This made it the third most common operation performed in the United States, accounting for approximately 1.2 billion dollars in health care expenditures. Although the number of procedures was substantially less in Canada and Europe, these countries too had seen a dramatic increase. This occurred despite the absence of properly designed prospective studies supporting the efficacy of the procedure. Between 1985 and 1990, the number of carotid endarterectomies declined due to a) concerns related to the paucity of evidence supporting its efficacy in patients with symptomatic carotid stenosis, b) the rising frequency of operation for inadequately validated indications (e.g., asymptomatic patients), c) wide variations in the reported rates of morbidity and mortality, and d) evidence that the overall incidence of stroke was declining.