Carotid endarterectomy

Abstract

A half-century ago the first surgical procedure to prevent stroke was reported in The Lancet. 1 Eastcott HHG Pickering GW Rob CG Reconstruction of internal carotid artery in a patient with intermittent attacks of hemiplegia. Lancet. 1954; 3: 994 Abstract Scopus (549) Google Scholar The patient in this epochal advance had had neurological symptoms in the carotid territory of the brain and angiography of the relevant carotid artery, which revealed stenosis.. The concept proved eruptive: within 25 years an estimated 1 million carotid endarterectomies had been done, mainly on patients with neurological symptoms (stroke or transient cerebral arterial ischaemia) who were then investigated angiographically, revealing stenosis. Ultrasonography extended the procedure to the potentially much larger population with asymptomatic lesions. The notion was explored that patients with only vertebral/basilar symptoms might benefit from carotid endarterectomy performed on asymptomatic carotid stenosing lesions. The results failed to be convincing of secondary benefit transferred from one arterial territory to another. Interest dwindled. Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomised controlled trialIn asymptomatic patients younger than 75 years of age with carotid diameter reduction about 70% or more on ultrasound (many of whom were on aspirin, antihypertensive, and, in recent years, statin therapy), immediate CEA halved the net 5-year stroke risk from about 12% to about 6% (including the 3% perioperative hazard). Half this 5-year benefit involved disabling or fatal strokes. But, outside trials, inappropriate selection of patients or poor surgery could obviate such benefits. Full-Text PDF