Selection Of Patients For Carotid Endarterectomy Research Articles

Risk Prediction Tools to Improve Patient Selection for Carotid Endarterectomy Among Patients With Asymptomatic Carotid Stenosis

This cohort study was conducted between January 1, 2005, and December 31, 2009. There were 2325 veterans 65 years and older who received both carotid imaging and carotid endarterectomy (CEA) and were observed for 5 years. In this study, 30% of patients died within 5 years. A risk production tool (Carotid Mortality Index) based on 23 variables identified in the literature using Veterans Administration and Medicare data was developed. A model based on the number of four key comorbidities (any cancer in the past 5 years, moderate or severe chronic obstructive pulmonary disease [COPD], congestive heart failure [CHF], chronic kidney disease [CKD]) was strongly associated with 5-year mortality. Use of this model may improve selection of patients for CEA among men with asymptomatic carotid stenosis.

Risk Prediction Tools to Improve Patient Selection for Carotid Endarterectomy Among Patients With Asymptomatic Carotid Stenosis

Randomized clinical trials have demonstrated that patients with asymptomatic carotid stenosis are eligible for carotid endarterectomy (CEA) if the 30-day surgical complication rate is less than 3% and the patient's life expectancy is at least 5 years. To develop a risk prediction tool to improve patient selection for CEA among patients with asymptomatic carotid stenosis. In this cohort study, veterans 65 years and older who received both carotid imaging and CEA in the Veterans Administration between January 1, 2005, and December 31, 2009 (n = 2325) were followed up for 5 years. Data were analyzed from January 2005 to December 2015. A risk prediction tool (the Carotid Mortality Index [CMI]) based on 23 candidate variables identified in the literature was developed using Veterans Administration and Medicare data. A simpler model based on the number of 4 key comorbidities that were prevalent and strongly associated with 5-year mortality was also developed (any cancer in the past 5 years, chronic obstructive pulmonary disease, congestive heart failure, and chronic kidney disease [the 4C model]). Model performance was assessed using measures of discrimination (eg, area under the curve [AUC]) and calibration. Internal validation was performed by correcting for optimism using 500 bootstrapped samples. Five-year mortality. Among 2325 veterans, the mean (SD) age was 73.74 (5.92) years. The cohort was predominantly male (98.8%) and of white race/ethnicity (94.4%). Overall, 29.5% (n = 687) of patients died within 5 years of CEA. On the basis of a backward selection algorithm, 9 patient characteristics were selected (age, chronic kidney disease, diabetes, chronic obstructive pulmonary disease, any cancer diagnosis in the past 5 years, congestive heart failure, atrial fibrillation, remote stroke or transient ischemic attack, and body mass index) for the final logistic model, which yielded an optimism-corrected AUC of 0.687 for the CMI. The 4C model had slightly worse discrimination (AUC, 0.657) compared with the CMI model; however, the calibration curve was similar to the full model in most of the range of predicted probabilities. According to results of this study, use of the CMI or the simpler 4C model may improve patient selection for CEA among patients with asymptomatic carotid stenosis.

Abstract 162: Ipsilateral Ischemic Stroke in Japanese Patients With Asymptomatic Carotid Stenosis on Recent Medical Treatment

Purpose: Owing to improvements of recent medical treatment, whether carotid endarterectomy (CEA) is beneficial for patients with asymptomatic carotid stenosis still remains controversial. This study was designed to clarify the risk of ipsilateral ischemic stroke in Japanese patients with asymptomatic carotid stenosis. Method: We studied the risk of TIA, ischemic stroke, coronary artery disease and death in 105 patients (mean age 76.2 years; woman 16) with asymptomatic carotid stenosis of 50% or more recruited consecutively from Jan 2009 and given recent medical treatment. Patients with any previous symptoms of ipsilatral TIA or stroke were excluded. Results: During a mean follow up of 2.74 years, there were 7 TIAs (one ipsilateral, 6 other territory) and 9 ischemic strokes (3 ipsilateral, 6 other territory). Two patients underwent subsequent CEA or carotid artery stenting, 7 had coronary artery disease, and 4 died during the follow-up period. The average annual event rate of ipsilateral ischemic stroke was 0.64% (95% CI, 0.08 to 4.72). Conclusion: The risk of ipsilateral ischemic stroke on recent medial treatment was very low. Benefit from CEA might be small, and selection of patients for CEA should include an assessment of coronary artery disease and life expectancy.

SS26. Improving Patient Selection for Carotid Endarterectomy in Asymptomatic Patients Based on Predicted Five-Year Survival

SS26. Improving Patient Selection for Carotid Endarterectomy in Asymptomatic Patients Based on Predicted Five-Year Survival

Abstract 7: Has Patient Selection for Carotid Endarterectomy and Stenting changed over time? Carotid revascularization in the postCREST era.

The results of CREST (Carotid Revascularization Endarterectomy versus Stenting Trial), announced in February 2010 added further insight to the issue of patient selection for carotid revascularization. Carotid artery stenting (CAS) was equivalent to carotid endarterectomy (CEA), perhaps better in the younger age group. CEA patients developed more perioperative myocardial infarctions, and CAS patients incurred more perioperative strokes. Our hypothesis was that following the announcement of the CREST results, characteristics of patients undergoing CAS would change to include younger patients and more cardiac disease compared with those undergoing CEA. Methods: a retrospective chart review was conducted of all carotid revascularization procedures performed at four hospitals in a metropolitan region. The study duration was from June 2009 (8 months prior to CREST) through May 2011 (16 months after CREST). Demographics and high surgical risk criteria were recorded. Comparisons were drawn between patients receiving the procedures prior to and after CREST. Results: The study included 483 procedures. Of the 174 preCREST procedures, 64(36.8%) were CEA and 110(63.2%) were CAS. Of the 309 postCREST procedures, 112(36.2%) were CEA and 197(63.8%) were CAS. The proportion of patients undergoing CEA for asymptomatic carotid disease did not change significantly (76.6% preCREST vs. 69.6% postCREST: p=0.42). There was a significant increase in the proportion undergoing CAS for asymptomatic disease (52.7% preCREST vs 65.5% postCREST: p=0.04). The patients undergoing CAS for nonspecific symptoms such as dizziness also increased(5.5% preCREST vs. 18.3% postCREST: p=0.002). The median age did not change significantly for either CEA(68.5years preCREST vs. 69.0years postCREST: p=0.95) or CAS(73.0years preCREST vs. 70years postCREST: p=0.23). The proportion of CAS patients ≥70 years somewhat decreased(58.2% preCREST vs.50.3% postCREST: p=0.18). In the CEA subgroup, there was a reduction in the proportion of patients with congestive heart failure (10.9% preCREST vs.2.7% postCREST: p=0.07) and recent myocardial infarction/angina(4.7% preCREST vs.0 postCREST: p=0.06). There was an increase in the proportion of patients undergoing CAS with congestive heart failure(27.3% preCREST vs.37.6% postCREST: p=0.05). Conclusions: The utilization of CAS for asymptomatic carotid disease and nonspecific symptoms has increased after CREST. There is a trend towards patients with cardiac disease getting CAS more often. In spite of an increased risk of perioperative stroke among the elderly CAS patients, half of the CAS procedures postCREST were performed in subjects ≥70 years. Careful consideration of the choice of carotid revascularization procedures is warranted in the light of the CREST study.

Stroke and death after carotid endarterectomy and carotid artery stenting with and without high risk criteria

Centers for Medicare and Medicaid Services (CMS) reimbursement criteria for carotid artery stenting (CAS) require that patients be high surgical risk or enrolled in a clinical trial. This may bias comparisons of CAS and carotid endarterectomy (CEA). We evaluate mortality and stroke following CAS and CEA stratified by medical high risk criteria. The Nationwide Inpatient Sample (2004-2007) was queried by ICD-9 code for CAS and CEA with diagnosis of carotid artery stenosis. Medical high risk criteria were identified for each patient including patients undergoing a coronary artery bypass and/or valve repair (CABG/V) during the same admission. Symptom status was defined by history of stroke, transient ischemic attack (TIA), and/or amarosis fugax. The primary outcome was postoperative death, stroke (complication code 997.02), and combined stroke or death, stratified by high risk vs non-high risk status and symptom status. Patient totals of 56,564 (10.5%) CAS and 482,394 (89.5%) CEA were identified. Half of the patients in each group were high risk. CABG/V was performed less commonly with CAS than CEA (2.8% vs 4.0%, P < .001). Patients undergoing CAS were more likely symptomatic than those undergoing CEA (13.1% vs 9.4%, P < .001). Mortality was higher after CAS than CEA for both high risk and non-high risk patients. Stroke was also higher after CAS for both high risk and non-high risk patients. Combined stroke or death was higher after CAS again for both high risk (asymptomatic 1.5% vs 1.2%, P < .05, symptomatic 14.4% vs 6.9%, P < .001) and non-high risk (asymptomatic 1.8% vs 0.6%, P < .001, symptomatic 11.8% vs 4.9%, P < .001). Combined stroke or death for patients undergoing CABG/V during the same admission was similar for CAS and CEA (4.8% vs 3.2%, P = .19). Multivariate predictors of combined stroke or death adjusted for age and gender included CAS vs CEA (odds ratio [OR] 2.4, P < .001), symptom status (OR 6.8, P < .001), high risk (OR 1.6, P < .001), and earlier year of procedure (OR 1.1, P < .01). In the United States from 2004 to 2007, CAS has a higher risk of stroke and death than CEA after adjustment for medical high risk criteria. Further analysis with prospective assessment of risk factors is needed to guide appropriate patient selection for CEA and CAS in the general population.

NONINVASIVE IMAGING MODALITIES IN DECISION MAKING ABOUT CAROTID ENDARTERECTOMY – A COMPARISON OF DUPLEX ULTRASOUND, CT- AND MR-ANGIOGRAPHY

Purpose: Determining degree and morphology of stenoses is important for surgical planning, but controversy remains regarding the optimal preoperative evaluation to facilitate patient selection for carotid endarterectomy.

Carotid Artery Imaging in the United Kingdom: A Postal Questionnaire of Current Practice

There has been a steady rise in the use of carotid duplex imaging in the selection of patients for carotid endarterectomy (CEA). Some would suggest that CEA could be safely performed without preoperative contrast angiography. The purpose of this study was to focus on the role of duplex imaging among vascular surgeons in the United Kingdom and to highlight current practices in imaging prior to CEA. A postal questionnaire was sent to all consultant members of the Vascular Surgical Society of Great Britain and Ireland about the choice of imaging prior to selection of patients for CEA, preoperative imaging, and choice of imaging (if any) in the confirmation of carotid occlusion indicated by duplex scanning. Of 396 questionnaires sent, 323 (82%) were returned. Of these, 259 (80%) consultants performed carotid surgery, 118 (45%) in university hospitals (UHs) and 141 (53%) in district general hospitals (DGHs). One hundred eighteen (100%) and 137 (97%) respondents, respectively, chose duplex scanning as their first-line investigation. Sixty (51%) respondents in UHs and 49 (35%) respondents in DGHs repeated duplex scanning immediately preoperatively, with 57 (95%) and 46 (94%), respectively, using duplex scanning. Forty-seven (40%) respondents in UHs and 78 (55%) respondents in DGHs would reconfirm an occlusion, with 30 (64%) and 48 (62%), respectively, using computed tomography and magnetic resonance imaging as their preferred tool. Our study shows that duplex scanning is the first-line imaging technique for patient selection for CEA by vascular surgeons in the United Kingdom. Magnetic resonance imaging and computed tomography are replacing conventional angiography where duplex scanning is equivocal.

Editorial Comment—Plaque Pathology and Patient Selection for Carotid Endarterectomy

Experienced carotid surgeons know that when performing a carotid endarterectomy, it is important to avoid excessive manipulation of the carotid bifurcation during dissection, especially when the patient has had recent symptoms from an “active” plaque. This study by Fisher et al comparing the pathology of carotid plaques obtained from the asymptomatic carotid endarterectomy trial, ACAS, to those taken from the symptomatic trial, NASCET, helps explain the danger. Plaques resected from symptomatic patients are more frequently ulcerated and have attached thrombus compared with asymptomatic plaques and, therefore, are at greater risk to embolize clot and atherosclerotic debris into the cerebral circulation during surgical mobilization. During carotid endarterectomy, the tube-like carotid plaque is cut length-wise and not infrequently torn, preventing a highly accurate gross or microscopic assessment. This might …

Ultrasound and angiography in the selection of patients for carotid endarterectomy.

The risk of ischemic stroke increases proportionately to the severity of carotid stenosis, and carotid endarterectomy is a durable procedure that reduces this risk. Although a combination of noninvasive tests, such as ultrasound and magnetic resonance angiography (MRA), have low misclassification rates compared with invasive angiography, the need for invasive angiography may not yet be obviated. Ultrasound appears to be a cost-effective screening strategy for a significant carotid stenosis that warrants angiographic confirmation and possible intervention. A combination of ultrasound and MRA appears to be the most common clinical pathway that can be accurate and cost-effective, if rigorous local validation of diagnostic criteria is performed. Ultrasound further supplements angiography by providing information about plaque morphology and physiologic measurements of collateralization of flow and vasomotor reactivity when additional tests, such as transcranial Doppler, are performed. Ultrasound and various angiographic imaging modalities have complementary value in patient selection for carotid endarterectomy. Currently, more invasive angiograms are being performed, due to a variety of new experimental interventions such as angioplasty and stenting, a subject of current clinical trials.

Magnetic resonance angiography is an accurate imaging adjunct to duplex ultrasound scan in patient selection for carotid endarterectomy

Purpose: The purpose of this study was to evaluate the accuracy of magnetic resonance angiography (MRA) for categorizing the severity of carotid disease relative to duplex ultrasound scan and cerebral contrast arteriography (CA) to determine if MRA imaging could replace the need for cerebral angiography in cases of indeterminate or inadequate duplex scan imaging. Methods: Seventy-four carotid bifurcations in 40 patients undergoing 45 carotid endarterectomies from 1996 to 1998 were imaged with duplex ultrasound scan; MRA (two-dimensional neck and three-dimensional intracranial, time-of-flight technique); and biplanar, digital subtraction cerebral arteriography. Studies were blindly reviewed by one reader who used established threshold velocity criteria for the duplex scan and the North American Symptomatic Carotid Endarterectomy Trial method for MRA and CA to determine the percentage of diameter reduction of the internal carotid artery (ICA). Disease severity was grouped into four categories (< 50%, 50%-74%, 75%-99% stenosis and occlusion), and the results of MRA and duplex ultrasound scan were compared with CA. Results: Sensitivity, specificity, positive predictive value, and negative predictive value for detection of > 50% ICA stenosis were 100%, 96%, 98%, and 100% for MRA and 100%, 72%, 88%, and 100% for duplex ultrasound scan, respectively; similarly, for detection of > 75% ICA stenosis values were 100%, 77%, 76%, and 100% for MRA and 90%, 74%, 72%, and 91% for duplex ultrasound scan, respectively. Both MRA and duplex ultrasound scan accurately differentiated all cases of > 95% stenosis (n = 7) from occlusion (n = 4). Short length ICA flow gaps were present on MRA in all cases of 75% to 99% stenosis and one half of cases of CA-defined 50% to 74% stenosis. In patients with 50% to 74% stenosis, the mean angiographic stenosis was significantly greater when a flow gap was present on MRA (64% ± 6%) versus no flow gap (57% ± 7%) (P =.04). There was overall agreement among duplex ultrasound scan, MRA, and CA in 73% of carotids imaged. Of the 24% discordant results between MRA and duplex ultrasound scan, MRA correctly predicted disease severity in all cases, and inaccurate duplex ultrasound scan results were due to overestimation in 83% of cases. The operative plan was altered by CA findings in only one patient (2%) after duplex ultrasound scan and MRA. Conclusions: MRA can accurately categorize the severity of carotid occlusive disease. Duplex ultrasound scan facilitates patient selection for carotid endarterectomy in most cases, but adjunct use of MRA improves diagnostic accuracy for > 75% stenoses and may obviate the need for cerebral arteriography when duplex scan results are inconclusive or demonstrate borderline disease severity. (J Vasc Surg 2000;32:429-40.)

Is There Differential Access to Carotid Endarterectomy Based on Gender?

The purpose of this study was to determine whether there was differential access to carotid endarterectomy (CEA) based on gender at our institution. In 1995, the year after ACAS results were published, 1774 carotid duplex studies were performed in our vascular laboratory in 765 men and 1009 women. The incidence of 50-99% carotid stenosis was 13% (n = 235) overall and did not differ between men (13.3%; 102/765) and women (13.2%; 133/1009). The frequency that patients subsequently underwent CEA was determined to assess whether men with significant carotid stenosis were more likely to undergo CEA than women. Attempts were made to contact patients with 50-99% stenosis directly. Data were available for 101 patients (41 men, 60 women) with 50-99% carotid stenosis diagnosed by carotid duplex. There was conflicting information regarding the possibility of gender bias in the selection of candidates for CEA: logistic regression analysis suggested that disease severity dictated surgical intervention, however, a significantly lower percentage of women with ICA/CCA peak systolic ratios > or =2.9 underwent CEA. This study cannot refute the possibility that gender bias existed in the selection of patients for CEA.

Surgical decision making for carotid endarterectomy and contemporary magnetic resonance angiography

Background: Benefit from carotid endarterectomy (CEA) centers on patient selection and percent stenosis as determined by cerebral angiography. However, angiography remains expensive and poses risks. Validated carotid duplex ultrasonography has proven to be an accurate tool for selecting patients for CEA. However, the role of another noninvasive test—magnetic resonance angiography (MRA)—remains uncertain. Because of recent advances in MRA hardware and software, we hypothesized that clinically appropriate patients could be accurately selected for CEA based on MRA alone. Methods: Fifty-four carotid arteries in 29 patients (with and without symptoms) underwent both three-dimensional time-of-flight MRA (1.5 Tesla) with multiple overlapping thin slab acquisition and biplanar intra-arterial digital subtraction angiography. All patients undergoing both tests over a 24-month period were included. The majority of these patients did not undergo carotid duplex ultrasound owing to the clinical practice of the hospital’s neurosurgery service. Staff radiologists interpreted each study. The accuracy of patient selection based on MRA was calculated using angiography as the standard (NASCET method). Since operative thresholds vary depending on clinical history, we considered four commonly used ranges of percent stenosis for CEA. Results: Patient selection accuracy of MRA alone was low, but increased as percent stenosis increased. Out of 10 occluded arteries by angiography, 5 were interpreted as patent with stenosis (70% to 99%) by MRA. One patent artery was misread as occluded on MRA. Conclusion: Reliance solely on contemporary MRA for surgical decision making cannot be justified in view of low accuracy, which leads to high rates of error in patient selection for CEA.

Overview and patient selection for carotid endarterectomy

This article reviews the risk factors, natural history, and treatment options for the management of atherosclerotic carotid artery disease. Preoperative considerations and indications for surgical intervention are also reviewed. Algorithms for the management of symptomatic and asymptomatic stenoses are presented.

Early outcome assessment for 2228 consecutive carotid endarterectomy procedures: the Cleveland Clinic experience from 1989 to 1995.

Several randomized trials now have established guidelines regarding patient selection for carotid endarterectomy (CEA) that have been widely accepted but have little relevance unless they are considered in the context of perioperative risk. The purpose of this study was to demonstrate the feasibility of early outcome assessment using a computerized database. Since 1989 demographic information and in-hospital results for all surgical procedures performed by the members of our department have been entered into a prospective registry. For the purpose of this report, we have analyzed the stroke and mortality rates for 2228 consecutive CEAs (2046 patients), including 1924 that were performed as isolated operations and 304 that were combined with simultaneous coronary artery bypass grafting (CABG). This series incidentally contains a total of 153 reoperations for recurrent carotid stenosis. The respective stroke and mortality rates were 0.5% and 1.8% for all isolated CEAs, 4.3% and 5.3% for all CEA-CABG procedures, and 4.6% and 2.0% for carotid reoperations. According to a multivariable statistical model, the composite stroke and mortality rate for isolated CEA was significantly influenced by female gender (p = 0.050), by the urgency of intervention (p = 0.026), and by carotid reoperations (p = 0.024). Gender (p = 0.030) and urgency (p = 0.040) also were associated with differences in the stroke rate alone; furthermore, the incidence of perioperative stroke was higher in conjunction with synthetic patching (odds ratio, 2.6; 95% confidence interval, 1.2 to 5.3) and was marginally higher with primary arteriotomy closure (odds ratio, 2.7; 95% confidence interval, 0.8 to 9.5) compared with vein patch angioplasty (1.3%). The method used to repair the arteriotomy was the only independent factor that qualified for the multivariable composite stroke and mortality models that were applied to the combined CEA-CABG procedures, but too few patients in this cohort had synthetic patches or primary closure to validate the perceived superiority of vein patching. Prospective outcome assessment is essential to reconcile the indications for CEA with its actual results, and it may lead incidentally to important observations concerning patient care.

Handbook of interventional radiologic procedures

Microsurgical carotid endarterectomy Julian Bailes and Robert Spetzler, Philadelphia, 1996, Lippincott-Raven, 220 pages, $150. This text of 200 pages contains 10 chapters by the senior editors, neurologic surgeons at Allegheny General Hospital (Pittsburgh) and the Barrow Neurologic Institute (Phoenix), as well as 15 other authors who are neurosurgeons, neuroanesthesiologists, neurologists, and neuroradiologists. Introductory chapters include overviews on the epidemiology and natural history of carotid stenosis, preoperative risk assessment, and patient selection for carotid endarterectomy. The next chapter reviews carotid angiography, magnetic resonance, and magnetic resonance arteriography, followed by chapters describing the anesthetic management during carotid endarterectomy and the operative technique itself, which is beautifully illustrated. The final chapters in the text discuss the postoperative medical management of the carotid endarterectomy patient and the unique management of total occlusion. As stated by the authors, the purpose of this text was to “collect the entire spectrum of care associated with microsurgical carotid endarterectomy into one reference volume.” Most of the chapters in the text are competent review and overview sections, but do not add new information to previously published texts on the management of the patient with cerebrovascular disease. Indeed, the significance of the 36-page chapter on “Rationale and Protocol for Microsurgical Carotid Endarterectomy” escapes this reviewer. The operative instructions offered are those that have been well described for decades, except the arteriotomy closure is performed with an operating microscope in lieu of loop magnification. The section, however, on perioperative complications including postoperative thrombosis, intracerebral hemorrhage, and controversies in carotid endarterectomy (ie, carotid patch angioplasty, intraoperative shunting) is quite good. The chapter discussing intraoperative transcranial Doppler (TCD) is well written and well-illustrated. The illustrative case examples of “competent vs incompetent collateral reserves,” microembolization, and carotid thrombosis were helpful in understanding TCD as an adjunct for cerebral surveillance during operation. The most intriguing chapter in the text was on management of total carotid occlusion. The authors reviewed and documented the natural history and operative results of internal carotid artery occlusion and report their results in 42 patients who underwent “emergency carotid endarterectomy for appropriate symptoms.” The authors opened 24 arteries with thromboembolectomy, performed internal carotid “stumpectomy” with external carotid ligation in nine, and stumpectomy with external carotid endarterectomy and EC-IC bypass in four. The long-term follow-up results demonstrate an 88% patency rate by color-flow ultrasonography in patients who initially were thrombectomized. The authors conclude that the natural history of carotid occlusion has been ill defined, and the authors believe they have improved their ability to reopen occluded arteries. An algorithm is presented as a management guideline. In general, this text is beautifully illustrated, well documented, and well written. It does not, however, offer much new about carotid endarterectomy, but would serve as an appropriate reference text. The receipt of the books listed below is acknowledged. This listing is regarded as appropriate return for the courtesy of the sender. The books that are of particular interest will be reviewed and the review published as space permits. Arterial aneurysms: Diagnosis and management Michael Horrocks, Oxford, Mass., 1995, Butterworth-Heinemann, 246 pages, $110. Noninvasive electrocardiology: Clinical aspects of Holter monitoring Arthur Moss and Shlomo Stern, Philadelphia, 1996, W.B. Saunders, 541 pages, $59. Computer analysis of cardiovascular signals M. DiRenzio, G. Marcia, G. Parati, H. Pedotti, A. Zanchetti, Amsterdam, 1995, IOS Press, 315 pages. Surgical treatment of aortic dissection Hams Borst, Markus Heinemann, and Christopher Stone, New York, 1996, Churchill Livingstone, 357 pages, $119.95. Venous disorders: A manual of diagnosis and treatment G. Belcaro, A.N. Nicolaides, and M. Veller, Philadelphia, 1995, W.B. Saunders, 204 pages, $35. Handbook of venous disorders: Guidelines of the American Venous Forum Peter Gloviczki and James S. T. Yao, London, 1996, Chapman & Hall Medical, 686 pages. Renal vascular disease Andrew Novick, John Sobule, and George Hamilton, Philadelphia, 1996, W.B. Saunders, 550 pages, $97. Atlas of cardiovascular pathology Renu Virmani, Allen Burke, and Andrew Farb, Philadelphia, 1996, W.B. Saunders, 234 pages, $169. Handbook of interventional radiologic procedures Krishna Kandarpa and John Aruny, Boston, 1996, Little, Brown and Company, 508 pages, $37.95.

Endarterectomy in Carotid Artery Disease

To the Editor.— The conclusions and recommendations for patient selection for carotid endarterectomy advanced by Matchar and Pauker1cannot be accepted because they ignore the most important fact: carotid endarterectomy has never been shown to be of any value for any patient under any circumstances. The authors admit that the only randomized controlled trial of endarterectomy failed to show a benefit,2yet they use this 20-year-old study to estimate the efficacy of the procedure in modern patients. There is mounting evidence, such as that from the large, prospective, randomized controlled trial of extracranial-intracranial bypass,3that surgical revascularization is of no benefit in preventing stroke. Whether carotid endarterectomy is also of no benefit is unknown, but there is no scientific evidence of its effectiveness. The relative risks of this procedure in different types of patients are irrelevant when there are no clear benefits. I appreciate the authors' attempt