Improving the appropriateness of carotid endarterectomy

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Carotid endarterectomy (CE) has been used for stroke prevention since its introduction in 1954.1 It was embraced with great enthusiasm in the 1980s and rates soared.2 However, the lack of efficacy data from randomized controlled trials (RCTs) and doubts about its effectiveness had at least three effects. Rates began to drop, a major study of the appropriateness of CE was undertaken,3 and RCTs were conducted. The result today should be more appropriate and effective use of CE. The 1988 RAND study of the appropriateness of CE3 revealed a disturbing result; about a third of procedures were judged inappropriate, based upon the best evidence and expert opinion; a third were of uncertain value; and only a third were appropriate.3 This result tempered enthusiasm for CE and rates dropped.2 It also helped persuade the National Institute of Neurologic Disorders and Stroke to support the first major RCT of CE, the North American Symptomatic Carotid Endarterectomy Trial (NASCET).4 NASCET showed that CE substantially reduced the risk of stroke in symptomatic patients with ≥70% stenosis and to a lesser degree in those with 50 to 69% stenosis. A large European RCT substantiated these results for symptomatic patients.5 The Asymptomatic Carotid Stenosis Trial (ACAS)6 showed a more modest reduction of stroke in asymptomatic patients with ≥60% carotid stenosis. Significant …