Comparing Carotid Endarterectomy Research Articles

Treatment of Symptomatic Carotid Stenosis: Carotid Stent Placement Versus Endarterectomy

The mainstay of treatment options for symptomatic carotid stenosis is focused around medical management, carotid endarterectomy, and carotid angioplasty and stent placement. The International Carotid Stenting Study (ICSS), also called Carotid and Vertebral Artery Transluminal Angioplasty Study 2 (CAVATAS 2), the Stent-Supported Percutaneous Angioplasty of the Carotid Artery Versus Endarterectomy (SPACE) trial, the Endarterectomy Versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis (EVA-3S) trial, the Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy (SAPPHIRE) trial, and the Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST) were five major trials which compared carotid endarterectomy and carotid angioplasty and stent placement. We review the results of the trials and incorporation of the results into clinical decision making.

An evidence‐based review of the impact of periprocedural myocardial infarction in carotid revascularization

Landmark trials comparing carotid endarterectomy (CEA) with medical therapy in patients with symptomatic or asymptomatic atherosclerotic stenosis of extracranial carotid arteries have favored carotid revascularization. Carotid artery stenting (CAS) has emerged as a minimally invasive option for revascularization of carotid artery stenoses and has been shown to be noninferior to CEA, regardless of patient symptom status. Debate continues regarding the importance of periprocedural myocardial infarction (PMI) as an endpoint in carotid revascularization trials. Recent randomized comparisons of CEA and CAS pre-specify PMI as an endpoint. Understanding PMI in CEA and CAS, the need for routine biomarker assessment surrounding both revascularization strategies, the effect of PMI on long-term morbidity and mortality, and the groups most at risk for PMI are of critical importance when choosing a carotid revascularization strategy for symptomatic and asymptomatic patients, since decreasing the incidence of PMI will make revascularization safer. This review examines available data regarding the relevance of PMI in vascular and carotid-specific outcomes.

Accuracy of administrative data versus clinical data to evaluate carotid endarterectomy and carotid stenting

Administrative data have been used to compare carotid endarterectomy (CEA) and carotid artery stenting (CAS). However, there are limitations in defining symptom status, Centers for Medicare and Medicaid Services high-risk status, as well as complications. Therefore, we did a direct comparison between administrative data and physician chart review as well as between data collected for the National Surgical Quality Improvement Program (NSQIP) and physician chart review for CEA and CAS. We performed an outcomes analysis on all CEA and CAS procedures from 2005 to 2011. We obtained International Classification of Diseases, Ninth Revision diagnosis codes from hospital discharge records regarding symptom status, high-risk status, and perioperative stroke. We also obtained data on all CEA patients submitted to NSQIP over the same time period. One of the study authors (R.B.) then performed a chart review of the same patients to determine symptom status, high-risk status, and perioperative strokes and the results were compared. We identified 1342 patients who underwent CEA or CAS between 2005 and 2011 and 392 patients who underwent CEA that were submitted to NSQIP. Administrative data identified fewer symptomatic patients (17.0% vs 34.0%), physiologic high-risk patients (9.3% vs 23.0%), and anatomic high-risk patients (0% vs 15.2%). Although administrative data identified a similar proportion of perioperative strokes (1.9% vs 2.0%), this was due to the fact that these data identified eight false positive and nine false negative perioperative strokes. NSQIP data identified more symptomatic patients compared with chart review (44.1% vs 30.3%), fewer physiologic high-risk patients (13.0% vs 18.6%), fewer anatomic high-risk patients (0% vs 6.6%), and a similar proportion of perioperative strokes (1.5% vs 1.8%, only one false negative stroke and no false positives). Administrative data are unreliable for determining symptom status, high-risk status, and perioperative stroke and should not be used to analyze CEA and CAS. NSQIP data do not adequately identify high-risk patients, but do accurately identify perioperative strokes and to a lesser degree, symptom status.

O-007 Carotid stent cell design modified the periprocedural outcomes in the stenting arm of randomized trials of carotid revascularization: a meta-analysis

IntroductionTrials describe a risk of stroke of about 6% following carotid artery stenting (CAS). Stent cell design has been implicated as a potential factor in these risks. The small free...

Carotid Endarterectomy Plus Medical Therapy or Medical Therapy Alone for Carotid Artery Stenosis in Symptomatic or Asymptomatic Patients: A Meta-Analysis

The purpose of this study was to compare carotid endarterectomy (CEA) plus medical therapy (MT) with MT alone for symptomatic and asymptomatic patients suffering from carotid artery stenosis in terms of long-term stroke/death rate. A meta-analysis of parallel randomized, controlled trials (RCTs) (blind or open) published in English. A university-based electronic search. Patients suffering from carotid artery stenosis symptomatic or not. Patients were subjected to CEA plus MT or MT alone. For asymptomatic patients, 6 RCTs comprising 5,733 patients (CEA = 2,853 and MT = 2,880) were included. CEA did not affect the stroke/death risk for asymptomatic patients (risk ratio [RR] = 0.93; 95% confidence interval [CI], 0.84 to 1.02; I(2) = 0%; p = 0.14). For symptomatic patients, 2 RCTs were included. They had 5,627 patients (CEA = 3,069 and MT = 2,558) of whom 2,295 patients (CEA = 1,213; MT = 1,082) had severe stenosis (North American Symptomatic Carotid Endarterectomy Trial [NASCET] technique ≥50% and European Carotid Surgery Trial technique ≥70%). CEA decreased the stroke/death risk only for patients with severe stenosis (RR = 0.69; 95% CI, 0.59-0.81; p < 0.001 [random effects model]; I(2) = 0% on the odds ratio and 17% on the RR [benefit or harm side]; number needed to treat = 11 [95% CI, 8-17]). CEA is helpful for recently symptomatic patients with carotid artery stenosis ≥50% (NASCET technique) but adds no benefit in terms of stroke/death for asymptomatic patients.

Carotid artery disease and interventional therapy

Major results of recent clinical trials for carotid artery disease are changing the understanding of management. A major trial comparing carotid endarterectomy with carotid angioplasty and stenting for symptomatic or asymptomatic patients suggests comparable results by overall outcomes analyses, and different results by subset analyses. These results modify the findings of prior trials. Based on age there appear to be differences in outcomes that may influence decision for management for such patients.

Revascularization of carotid artery stenosis - a brief update on current evidence

Major and long-awaited trials comparing carotid endarterectomy (CEA) with carotid stenting (CAS) were published in recent years. Both, ICSS and CREST, documented a higher rate of periprocedural stroke and death in CAS, in particular in elderly patients, thereby confirming the results of prior trials and meta-analyses. In CREST, the composite endpoint included myocardial infarction (MI), which led to statistical equipoise between the treatment arms due to a higher rate of MI with CEA. However, whether MI is a relevant endpoint in trials for stroke prevention remains debatable. The stroke preventive benefit seems equally sustained after CEA and CAS, although the significance of restenoses, whose frequency is twice as high after CAS compared to CEA, is unclear in the long range. Emergent CEA in patients with clinically unstable carotid stenosis is associated with a very high complication risk, but the optimal treatment strategy for these patients remains to be elucidated. Recent evidence indicates a very low stroke risk of asymptomatic stenoses with intensive medical treatment, rendering revascularization almost unnecessary. The detection of microembolic signals on transcranial Doppler and rapid stenosis progression by duplex sonography might help to identify patients with higher stroke risk in whom revascularization is warranted.

Clinical considerations in the management of asymptomatic carotid artery stenosis

Incidental findings pose considerable management dilemmas for the treating physician and psychological burden for the respective patient. With an aging population, more patients will be diagnosed with asymptomatic internal carotid artery stenosis. Patients will have to be counseled with regard to treatment options according to their individual risk profile and according to professionals' knowledge of evidence-based data derived from large randomized control trials. Treatment consensus has long been lacking for patients with asymptomatic carotid artery stenosis prior to any randomized controlled trials. Additionally, an individual's risk profile may be hard to assess according to knowledge gained from randomized controlled trials. Moreover, while earlier studies compared carotid endarterectomy and medical therapy, in the past years, a new therapeutic modality, carotid artery angioplasty and stenting, has emerged as a possible alternative. This has been evaluated in a recent randomized controlled trial, the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST), which compared carotid endarterectomy with angioplasty and stenting in both symptomatic and asymptomatic patients. The following review summarizes current knowledge of the natural history, diagnosis, and treatment strategies to counsel patients with asymptomatic carotid artery stenosis.

Updated Society for Vascular Surgery guidelines for management of extracranial carotid disease

Management of carotid bifurcation stenosis is a cornerstone of stroke prevention and has been the subject of extensive clinical investigation, including multiple controlled randomized trials. The appropriate treatment of patients with carotid bifurcation disease is of major interest to the community of vascular surgeons. In 2008, the Society for Vascular Surgery published guidelines for treatment of carotid artery disease. At the time, only one randomized trial, comparing carotid endarterectomy (CEA) and carotid stenting (CAS), had been published. Since that publication, four major randomized trials comparing CEA and CAS have been published, and the role of medical management has been re-emphasized. The current publication updates and expands the 2008 guidelines with specific emphasis on six areas: imaging in identification and characterization of carotid stenosis, medical therapy (as stand-alone management and also in conjunction with intervention in patients with carotid bifurcation stenosis), risk stratification to select patients for appropriate interventional management (CEA or CAS), technical standards for performing CEA and CAS, the relative roles of CEA and CAS, and management of unusual conditions associated with extracranial carotid pathology. Recommendations are made using the GRADE (Grades of Recommendation Assessment, Development and Evaluation) system, as has been done with other Society for Vascular Surgery guideline documents.[corrected] The perioperative risk of stroke and death in asymptomatic patients must be <3% to ensure benefit for the patient. CAS should be reserved for symptomatic patients with stenosis of 50% to 99% at high risk for CEA for anatomic or medical reasons. CAS is not recommended for asymptomatic patients at this time. Asymptomatic patients at high risk for intervention or with <3 years life expectancy should be considered for medical management as the first-line therapy.

Asymptomatic Carotid Surgery Trial-2 (ACST-2): Rationale for a Randomised Clinical Trial Comparing Carotid Endarterectomy with Carotid Artery Stenting in Patients with Asymptomatic Carotid Artery Stenosis

To compare carotid endarterectomy with carotid artery stenting in the prevention of stroke in patients with asymptomatic carotid stenosis. A large, simple, pragmatic international trial of at least 5000 patients with asymptomatic carotid stenosis in whom intervention is thought to be needed but where there is substantial uncertainty about the appropriate choice of treatment. The trial is designed to fit in easily with normal clinical practice. A short (approximately 2 min) telephone call is made to randomise patients to either carotid endarterectomy (CEA) or stenting (CAS). Follow-up by the collaborator will be at one month after the procedure (simple 1-page form) and by the ACST office for 5-years post-procedure. Data will be analysed on an intention-to-treat basis; main outcomes will be 30-day myocardial infarction, stroke and death, and 5-year stroke rates. In addition, appropriate subgroup analyses will be undertaken, and health economic evaluation will consider procedural and stroke-related healthcare costs and quality of life. Collaborators who routinely undertake CEA and CAS are encouraged to participate in ACST-2. This trial, now funded and open for randomisation, will provide important evidence comparing the immediate and long-term safety and efficacy of carotid endarterectomy and stenting in patients with asymptomatic carotid stenosis.

Neuropsychological consequences of endarterectomy and endovascular angioplasty with stent placement for treatment of symptomatic carotid stenosis

Previous studies compared carotid endarterectomy (CEA) and carotid artery stent placement (CAS) for treatment of symptomatic carotid artery stenosis. Whereas most previous studies showed both treatment modalities to be associated with a comparable risk of periprocedural cerebrovascular complications, these previous studies have shown significantly more microemboli and significantly more lesions in diffusion-weighted MR imaging after CAS compared to CEA. The clinical relevance of these differences remains unknown. We therefore compared the neuropsychological consequences of CAS and CEA and additionally measured the S100beta protein, a marker of cerebral damage. A total of 48 patients with symptomatic carotid artery stenosis greater than 70 % (according to ECST criteria) were enrolled and 45 patients participated in the follow-up. The patients were randomly assigned for CEA (24 patients) or CAS (21 patients). S100beta protein values were evaluated 2 hours before the procedure, as well as one and two hours thereafter. Patients were assessed before treatment, and again 6 and 30 days after treatment using a comprehensive neuropsychological test battery. Patients of the CAS and the CEA groups did not significantly differ in terms of age, gender, education, degree of carotid artery stenosis, cerebrovascular symptoms and vascular risk factors. Following previously used criteria, a cognitive change in patients was assumed to have occurred when there was a decline of more than one standard deviation in two or more tests assessing various cognitive domains. Six days and 30 days after the treatment both groups showed a comparable number of patients with cognitive changes compared to baseline. There were no significant differences in S100beta protein values. These results provide some reassurance that CAS is not associated with greater cognitive deterioration than CEA is.

Carotid-Stenosis Repair: SPACE for Another CEA vs. Stenting Trial

In a partly industry-funded, randomized trial conducted in Germany, Austria, and Switzerland, researchers compared carotid endarterectomy (CEA; the

Advances in Interventional Neuroradiology 2005

In the wake of the SAPPHIRE trial1 and subsequent approval of carotid stenting (CAS) devices by the Food and Drug Administration (FDA) in the United States, CAS is poised to explode in the frequency of its application in North America. Although the results of the Carotid Revascularization Stenting versus Endarterectomy Trial (CREST), the largest randomized controlled trial comparing carotid endarterectomy to CAS, are years away, many practitioners in multiple disciplines have already entered the competition for patients and remuneration. Despite the absence of evidence to support CAS over carotid endarterectomy2,3 and the need to continue recruiting patients to CREST,4 cardiologists, vascular surgeons, neurologists, neurosurgeons, general interventional and neurointerventional radiologists are all vying to treat carotid stenoses, many of which are <70% in severity, and asymptomatic.2,5,6 Attempts are being made to establish training, competency and credentialing standards for performance of CAS, and they vary widely between specialties.7,8,9 Computer simulations are playing a larger role in this process10 and may help to address the mismatch between training opportunities and interested practitioners. There have been concerns about the SAPPHIRE trial11 and the incidence of restenosis in previous case series.3,12 The techniques of CAS are still variable, with some operators advocating the use of cerebral protection devices,13 whereas others found that distal emboli might be more common with their usage.14 Although abnormalities on diffusion-weighted MRI after CAS are not uncommon (up to 30% of patients), most of these are asymptomatic.15 Patient related risk factors might be important determinants of complication rates after CAS, with those …

Limitations to the Value of the Sapphire Trial

The Sapphire trial was organised as a randomised trial to compare carotid endarterectomy (CEA) with carotid angioplasty and stenting (CAS) using a protection device in so called high risk patients. The trial concluded that CEA and CAS were similar as far as stroke and death are concerned but CAS was superior when other complications were taken into account. The trial was flawed for several reasons. It was commercially funded and the inventor of the protection device was one of the investigators and therefore not in equipoise. The end points of the trial favoured CAS by making a biochemical myocardial event an end point. The surgeons doing CEA in the trial did relatively few CEA’S per year and had a high stroke and death rate. These surgeons also excluded over 400 patients from the trial because they were said to be too difficult or risky to operate on. The precise reasons for this exclusion have never been made clear except that the surgeons were probably inexperienced. Finally the patients were heterogeneous, more than 70% being asymptomatic or suffering from recurrent stenosis. For all of these reasons the Sapphire trial’s conclusions that CAS is equivalent to CEA in high risk patients cannot be scientifically justified.

Cerebral protection devices for use during carotid artery angioplasty with stenting: A health technology assessment

This study sought to examine the safety, efficacy, and economic implications of the use of cerebral protection devices during carotid artery angioplasty and stenting (CAS) in high-risk patients with severe carotid artery disease (CAD). A comprehensive search for peer- and non-peer-reviewed studies that compared carotid endarterectomy (CEA) or CAS without cerebral protection to CAS with cerebral protection and appeared in the English language literature between January 1990 and January 2005 was completed. Information from studies identified was extracted using a common data abstraction form and then critically appraised against published quality assessment criteria. Of the eight studies found, six provided information on technical or procedural success rates, with values ranging from 95.6 percent to 100 percent. Three of the four studies comparing groups of patients who received CAS with cerebral protection with those who received only CAS reported a non-statistically significantly higher 30-day incidence of death and stroke (major or minor) in the latter group. None of the three studies comparing CAS with cerebral protection to CEA demonstrated a statistically significant difference in the 30-day incidence of death, major stroke, or myocardial infarction between treatment groups. No economic analyses were found. In high-risk patients with severe CAD, the evidence suggests that CAS with cerebral protection may offer a safe and efficacious alternative to CEA, reducing the risk of embolic peri-procedural complications associated with CAS to acceptable levels.

Neuropsychological consequences of endarterectomy and endovascular angioplasty with stent placement for treatment of symptomatic carotid stenosis: a prospective randomised study

Background and purpose: Previous studies compared carotid endarterectomy (CEA) and carotid artery stent placement (CAS) for treatment of symptomatic carotid artery stenosis. Whereas both treatment modalities are associated with a comparable risk of periprocedural cerebrovascular complications, CAS seems to lead to significantly more microemboli and more lesions in diffusion-weighted MR imaging. The clinical relevance of these differences remains unknown. We therefore compared the neuropsychological consequences of CAS and CEA and additionally measured the S100ß protein, a marker of cerebral damage.

Endarterectomy or angioplasty for treatment of carotid stenosis?

The Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS) reported in today's Lancet is not the first randomised clinical trial to compare carotid endarterectomy with angioplasty, but it may be the first to be completed. A previous study was stopped early, after only 23 patients were enrolled, because of significantly worse outcomes among patients randomised to angioplasty. 1 Naylor AR Bolia A Abbott RJ et al. Randomized study of carotid angioplasty and stenting versus carotid endarterectomy: a stopped trial. J Vasc Surg. 1998; 28: 326-334 Summary Full Text PDF PubMed Scopus (456) Google Scholar Endovascular versus surgical treatment in patients with carotid stenosis in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS): a randomised trialEndovascular treatment had similar major risks and effectiveness at prevention of stroke during 3 years compared with carotid surgery, but with wide CIs. Endovascular treatment had the advantage of avoiding minor complications. Full-Text PDF

Systematic Comparison of the Early Outcome of Angioplasty and Endarterectomy for Symptomatic Carotid Artery Disease

HomeStrokeVol. 31, No. 10Systematic Comparison of the Early Outcome of Angioplasty and Endarterectomy for Symptomatic Carotid Artery Disease Free AccessOtherPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toFree AccessOtherPDF/EPUBSystematic Comparison of the Early Outcome of Angioplasty and Endarterectomy for Symptomatic Carotid Artery Disease Joseph S. Jeret Joseph S. JeretJoseph S. Jeret Rockville Centre, New York Search for more papers by this author Originally published1 Oct 2000https://doi.org/10.1161/01.STR.31.10.2517-dStroke. 2000;31:2517–2527To the Editor: Three days before reading the article by Golledge et al,1 I recommended carotid stenting to a 74-year-old patient with critical asymptomatic left internal carotid artery stenosis. After reading the article, I was tempted to reconsider my recommendation, but a closer analysis reveals multiple flaws in the reasoning of Golledge et al.The authors cite 14 endovascular studies published from 1992 through 1998 involving a total of 714 carotid arteries, of which 230 were treated with stenting. Three of the studies recruited fewer than 15 patients. The 20 studies on carotid endarterectomy (including the authors’ own article) were published from 1990 through 1999 and recruited 63 to 1997 patients. One cannot compare carotid endarterectomy, a technology that is several decades old, to carotid stenting, a technique that is only several years old. Carotid stenting has a very significant learning curve. To compare carotid endarterectomy in its infancy to carotid stenting in its infancy would be more valid.I explained to my patient that he was being referred to a physician who had performed some 700 procedures (Dr Gary Roubin, personal communication, June 5, 2000). Vascular surgeons such as Dr Golledge may envision a “turf war” with the endovascular experts. I view stenting as a safer, less-invasive approach for my patients—provided that they are not part of the physician’s “learning curve.” References 1 Golledge J, Mitchell A, Greenhalgh RM, Davies AH. Systematic comparison of the early outcome of angioplasty and endarterectomy for symptomatic carotid artery disease. Stroke..2000; 31:1439–1443.CrossrefMedlineGoogle ScholarstrokeahaStrokeStrokeStroke0039-24991524-4628Lippincott Williams & WilkinsResponseGolledge Jonathan, MChir102000angioplastycarotid endarterectomycarotid stenosisI read with interest the comments of Dr Jeret regarding our article published in Stroke this year. Dr Jeret correctly states that a number of the series of carotid angioplasty were small, while in general the carotid endarterectomy series were larger. Dr Jeret also points out correctly that carotid stenting is an evolving technique at present. It is also true to state that carotid endarterectomy has been demonstrated in enormous randomized controlled trials as the treatment of choice for patients with symptomatic severe carotid stenosis; unfortunately, such data is not available for carotid stenting. Dr Jeret states “I view stenting as a safer, less-invasive approach for my patients.” Where are the data for this? Surely, the only scientific way of proving the value of stenting is from randomized control trials. As stated in our article, only 1 published randomized trial presently exists.R1 This study was stopped after only recruiting around 15 patients because of the severe complications with the stenting group.Ideally, we would have liked to perform a meta-analysis comparing randomized studies of stenting with carotid endarterectomy; owing to the paucity of randomized trials, such a comparison was not possible. Due to the increasing numbers of reported series of carotid stenting, we felt that some sort of comparison was badly needed so we could correctly advise patients of the most appropriate treatment at present. Hence the analysis we presented in our article, which shows that in the present state of the art, carotid stenting would not be advised for most patients with symptomatic carotid artery disease. Surely if we are to introduce a new technique for the treatment of symptomatic carotid artery disease we have to ensure that it is safe to do so, in both the short and long terms. The present data would suggest that carotid stenting is not a safe option in the majority of hands and therefore should be introduced only as part of carefully controlled studies. I would disagree with Dr Jeret’s opinion and feel that the flaws in the reasoning come from Dr Jeret’s idea that the evidence presently available demonstrates that stenting is a safer option. Previous Back to top Next FiguresReferencesRelatedDetailsCited By Levine R (2001) In Response, Journal of Neuroimaging, 10.1111/j.1552-6569.2001.tb00081.x, 11:4, (452-453), Online publication date: 1-Oct-2001. October 2000Vol 31, Issue 10Article InformationMetrics Copyright © 2000 by American Heart Associationhttps://doi.org/10.1161/01.STR.31.10.2517-d Originally publishedOctober 1, 2000 PDF download Advertisement

Scientific evidence demonstrating the safety of carotid angioplasty and stenting: Do we have enough to draw conclusions yet?

Scientific evidence demonstrating the safety of carotid angioplasty and stenting: Do we have enough to draw conclusions yet?

Cost-effective evaluation and treatment for carotid disease.

To compare carotid endarterectomy (CEA) based solely on Duplex ultrasonography (DU) with CEA based on DU and arteriography. Retrospective case series analysis in a regional tertiary care center. Consecutive sample of 194 patients undergoing 218 CEAs from January 1, 1993, through June 30, 1995, with either preoperative DU plus arteriography (165 CEAs) or DU only (53 CEAs). Concordance of the 2 diagnostic imaging techniques and influence of these on the conduct of surgery, surgical outcome, and resource cost. There was agreement (kappa = 0.85) between DU and arteriography in the detection of a carotid occlusion or a stenosis greater than 45%. Arteriography demonstrated 26 aortic arch branch lesions (15.8%), 22 intracranial abnormalities (13.3%), and 6 type C ulcers (3.6%), in addition to 1 nonoccluded internal carotid artery (ICA) (0.61%) and 1 contralateral severe ICA stenosis (0.61%) inaccurately estimated by Duplex. These findings prompted 3 changes (1.8%) in surgical therapy, including 2 decisions in favor of CEA and 1 subclavian-carotid bypass added to CEA. There was no difference in the stroke and death rate for CEA based solely on DU compared with CEA based on DU and arteriography (P = .43). The mean total hospital cost was $5,534 for DU only CEA vs $7,608 for DU plus arteriogram CEA (mean difference = $2,074, P < .01). The addition of carotid arteriography to a diagnostic Duplex ultrasound study that already suggested the need for CEA did not change the operative plan in 98% (162/165) of the cases. Carotid endarterectomy based solely on DU is appropriate and cost-effective.