Use Of Carotid Endarterectomy Research Articles

Use of Transcarotid Artery Revascularization, Transfemoral Carotid Artery Stenting, and Carotid Endarterectomy in the US From 2015 to 2019

A transcarotid artery revascularization (TCAR) device was approved by the US Food and Drug Administration in 2015 for carotid revascularization in patients at high risk for stroke, cranial nerve injury, or major cardiac event. It is unclear how the introduction of TCAR has changed the use of carotid endarterectomy (CEA) and transfemoral carotid artery stenting (TFCAS). To quantify the temporal changes in the operative approach to carotid revascularization (CEA vs TFCAS vs TCAR), and to identify patient and disease characteristics commonly associated with each approach. This retrospective cohort study obtained data from the Vascular Quality Initiative database from January 1, 2015, to December 31, 2019. Patients with carotid artery stenosis who underwent CEA, TFCAS, or TCAR were included. Data were analyzed from January to April 2022. Month and year of surgery as well as patient risk status. Number and proportion of carotid revascularization procedures by operative approach. A total of 108 676 patients (mean [SD] age 56.6 [12.5] years; 66 684 men [61.4%]) were included in the analysis. The most common operative approach overall was CEA (n = 81 508 [75.0%]), followed by TFCAS (n = 15 578 [14.3%]) and TCAR (n = 11 590 [10.7%]). The number of procedures increased over the study period (16 754 in 2015 vs 27 269 in 2019; P < .001). In 2015, CEA was used in 84.9% of all cases, followed by TFCAS (14.4%) and TCAR (0.8%). In 2019, CEA was used in 64.8% of cases, followed by TCAR (21.9%) and TFCAS (13.3%). The proportional use of CEA decreased by 5.0% (95% CI, -7.4% to -2.6%) per year, and TCAR use increased by 5.3% (95% CI, 2.3%-8.3%) per year. Among patients at high risk, the change was greater: CEA use decreased by 7.8% (95% CI, -11.9% to -3.8%) per year, TFCAS decreased by 4.8% (95% CI, -9.5% to -0.14%) per year, and TCAR increased by 12.6% (95% CI, 7.1%-18.1%) per year. Multinomial logistic regression showed that patient risk status was the most important characteristic associated with TCAR compared with CEA (relative risk ratio, 36.10; 95% CI, 29.24-44.66; P < .001) and TFCAS (relative risk ratio, 14.10; 95% CI, 11.86-16.66; P < .001). Linear regression revealed no association between year of surgery and in-hospital myocardial infarction, stroke, or mortality. Results of this study indicate that TCAR has become the dominant carotid revascularization approach, surpassing TFCAS and CEA in patients at high risk for stroke, cranial nerve injury, or cardiovascular events. Patient high-risk status was the main characteristic associated with a stenting approach, highlighting the perceived importance of carotid stenting therapies in this patient population.

Long-term stroke risk with carotid endarterectomy in patients with severe carotid stenosis

ObjectiveInformed debate regarding the optimal use of carotid endarterectomy (CEA) for stroke risk reduction requires contemporary assessment of both long-term risk and periprocedural risk. In this study, we report long-term stroke and death risk after CEA in a large integrated health care system. MethodsAll patients with documented severe (70%-99%) stenosis from 2008 to 2012 who underwent CEA were identified and stratified by asymptomatic or symptomatic indication. Those with prior ipsilateral interventions were excluded. Patients were followed up through 2017 for the primary outcomes of any stroke/death within 30 days of intervention and long-term ipsilateral ischemic stroke; secondary outcomes were any stroke and overall survival. ResultsOverall, 1949 patients (63.2% male; mean age, 71.3 ± 8.9 years) underwent 2078 primary CEAs, 1196 (58%) for asymptomatic stenosis and 882 (42%) for symptomatic stenosis. Mean follow-up was 5.5 ± 2.7 years. Median time to surgery was 72.0 (interquartile range, 38.5-198.0) days for asymptomatic patients and 21.0 (interquartile range, 5.0-55.0) days for symptomatic patients (P < .001). Most of the patients' demographics and characteristics were similar in both groups. Controlled blood pressure rates were similar at the time of CEA. Baseline statin use was seen in 60.5% of the asymptomatic group compared with 39.9% in the symptomatic group (P < .001), and statin adherence by 80% medication possession ratio was 19.3% asymptomatic vs 12.4% symptomatic (P < .001). The crude overall 30-day any stroke/death rates were 0.9% and 1.5% for the asymptomatic group and the symptomatic group, respectively. The 5-year risk of ipsilateral stroke and a combined end point of any stroke/death by Kaplan-Meier survival analysis were 2.5% and 28.7% for the asymptomatic group and 4.0% and 31.4% for the symptomatic group, respectively. Unadjusted cumulative all-cause survival was 74.2% for the asymptomatic group and 71.8% for the symptomatic group at 5 years. ConclusionsIn a contemporary review of CEA, outcomes for either operative indication show low adverse events perioperatively and low long-term stroke risk up to 5 years. These results are well within consensus guidelines and published trial outcomes and should help inform the discussion around optimal CEA use for severe carotid stenosis.

Author response: Lower carotid revascularization rates after stroke in racial/ethnic minority-serving US hospitals.

We respectfully disagree with Dr. Willey's conclusions about our study.1 The International Classification of Diseases, Ninth Revision, Clinical Modification ( ICD-9-CM ) codes used in our study (433.11 and 433.31) do not apply to asymptomatic internal carotid artery (ICA) stenosis and only capture extracranial disease resulting in infarction.2,3 Therefore, racial differences in the prevalence of intracranial disease or in the use of carotid endarterectomy (CEA) or carotid artery stenting (CAS) in asymptomatic ICA stenosis are an unlikely source of bias. The included ICD-9-CM codes indeed also capture patients with <50% stenosis or complete ICA occlusions, for whom revascularization would not be appropriate. We acknowledge this in the discussion as a well-known limitation of the data source; this has also been commented on elsewhere.4 However, it is important to distinguish differences between white and minority patients from differences between white and minority hospitals. Our results describe the latter and are adjusted for, and therefore independent of, individual patient race and other socioeconomic covariates. In other words, differences in eligibility by individual patient race/ethnicity may in part explain within-hospital differences between white and minority patients but would not explain between-hospital differences among patients of the same race. Figure 3 shows that the between-hospital difference in carotid revascularization is driven by lower odds of CEA/CAS in whites and Hispanics in minority, compared with white, hospitals. Individual-level racial differences in eligibility would not explain why white patients in minority-serving hospitals have lower adjusted odds of CEA/CAS than white patients in white hospitals or why Hispanic patients in minority-serving hospitals have lower adjusted odds of CEA/CAS than Hispanic patients in white hospitals. Last, we did not exclude transferred patients as suggested by Dr. Willey. Rather, we excluded records of patients transferred out to another acute care hospital while including those who were transferred in. Since the unit of observation in the data source is hospitalization, this is common practice to prevent double counting of transferred patients who may have 2 hospitalizations pertaining to the same event; this reduces rather than introduces bias.

The asymptomatic octogenarian and carotid endarterectomy—While we await the results of CREST-2

Currently there is no definitive level I evidence regarding the appropriate management of asymptomatic moderate to severe carotid artery stenosis in the octogenarian patient. In this 5-year review of National Surgical Quality Improvement Program registry data, exceptional “real-world” results are reported with use of carotid endarterectomy (CEA) in this growing cohort.1Glousman B.N. Sebastian R. Macsata R. Kuang X. Yang A. Patel D. et al.Carotid endarterectomy for asymptomatic carotid stenosis is safe in octogenarians.J Vasc Surg. 2020; 71: 518-524Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar The combined stroke and death rate was 2% at 30-day follow-up (stroke rate 1%!), with the authors stating that “age alone should not interdict this modality.” As the authors acknowledge, the most notable limitations of this study are the significant preoperative selection bias apparent in the octogenarians undergoing CEA and the considerably larger number of younger patients studied (nearly five times more) than octogenarians. Other factors include that approximately 25% of all of the study subjects were treated with CEA for only 50% to 79% carotid stenosis, lack of use of standard preoperative carotid imaging or grading criteria for selection to undergo CEA, 30-day follow-up only, and absence of data regarding preoperative cardiovascular risk stratification to determine fitness for surgery. Despite the noted limitations of the database used, the authors have demonstrated that with proper selection and execution, results with use of CEA in the fit octogenarian with asymptomatic carotid artery stenosis can be equivalent to those obtained in younger patients. Whereas this is clearly not level I evidence, it does again confirm that properly applied CEA remains an extremely safe and efficacious treatment modality even in octogenarians. The opinions or views expressed in this commentary are those of the author and do not necessarily reflect the opinions or recommendations of the Journal of Vascular Surgery or the Society for Vascular Surgery. Carotid endarterectomy for asymptomatic carotid stenosis is safe in octogenariansJournal of Vascular SurgeryVol. 71Issue 2PreviewCarotid endarterectomy (CEA) is the gold standard to prevent a recurrent stroke in symptomatic patients with carotid stenosis. However, in the modern era, the benefit of CEA in asymptomatic octogenarian patients has come into question. This study investigates real-world outcomes of CEA in asymptomatic octogenarians. Full-Text PDF

A modern view on revascularisation of brain and myocardium in patients with multifocal atherosclerosis: A review

Among cardiovascular diseases, multifocal atherosclerosis has begun occurring more frequently in the recent years; its manifestations such as coronary heart disease and acute cerebrovascular disease are the primary cause of death and disability worldwide. Both open and endovascular methods of surgical revascularisation of the brain and myocardium are presently used for addressing this global epidemic. Therefore, the outcomes and disease course during both the early postoperative and long-term periods in patients with multifocal atherosclerosis depend on the choice of appropriate surgical strategies. However, there is no consensus on the optimal strategies for the combined treatment of lesions in the coronary and cerebral basins. Consequently, there are no clinical recommendations or randomised trials that provide recommendations on the choice of treatment approaches in this cohort of patients. The specific treatment options are based on the personal experience of the clinic and the decision of the multidisciplinary team.Nevertheless, it is certain that carotid endarterectomy remains the gold standard for the treatment of significant stenosis of internal carotid artery, including that with complex anatomical characteristics and severe calcification; carotid endarterectomy is also the most important preventative measure for the acute violation of cerebral circulation. In addition, given the emergence of new coronary stents and the spread of intravascular imaging methods, percutaneous coronary intervention is increasing its evidence base by the year by demonstrating efficacy even in patients with concomitant left coronary artery trunk and multi-vascular coronary bed lesions.The use of carotid endarterectomy in combination with percutaneous coronary intervention in patients with lesions in both vascular basins for achieving hybrid revascularisation is promising although studied minimally.Therefore, in the present review, we aimed to present the current understanding of the methods utilised for revascularisation of the brain and myocardium as well as the hybrid revascularisation approach for the treatment of patients with multifocal atherosclerosis, with consideration given to its advantages and prospects.Received 12 April 2019. Revised 17 December 2019. Accepted 24 December 2019.Funding: The study did not have sponsorship.Conflict of interest: Authors declare no conflict of interest.

Lower carotid revascularization rates after stroke in racial/ethnic minority-serving US hospitals.

We sought to determine whether the use of carotid revascularization procedures after stroke due to carotid stenosis differs between minority-serving hospitals and hospitals serving predominantly white patients. We identified ischemic stroke cases due to carotid disease, identified by ICD-9-CM codes, from 2007 to 2011 in the Nationwide Inpatient Sample. The use of carotid endarterectomy (CEA) and carotid artery stenting (CAS) was recorded. Hospitals with ≥40% racial/ethnic minority patients (minority-serving hospitals) were compared to hospitals with <40% minority patients (predominantly white hospitals [hereafter, abbreviated to white]). Logistic regression was used to evaluate the use of CEA/CAS among minority-serving and white hospitals. Of the 26,189 ischemic stroke cases meeting inclusion criteria, 20,870 (79.7%) were treated at 1,113 white hospitals and 5,319 (20.3%) received care at 325 minority-serving hospitals. Compared to patients in white hospitals, patients in minority-serving hospitals were less likely to undergo CEA/CAS (17.6%, 95% confidence interval [CI] 16.6%-18.6%, in minority-serving vs 21.2%, 95% CI 20.7%-21.8%, in white hospitals; p < 0.001). In fully adjusted logistic regression models, the odds of CEA/CAS were lower in minority-serving compared to white hospitals (odds ratio 0.81, 95% CI 0.70-0.93), independent of individual patient race/ethnicity and other measured hospital characteristics. White and Hispanic individuals had significantly lower odds of CEA/CAS in minority-serving compared to white hospitals. Patient-level racial/ethnic differences in the use of carotid revascularization procedures remained within each hospital stratum. The odds of carotid revascularization after stroke is lower in minority- compared to white-serving hospitals, suggesting system-level factors as a major contributor to explain race disparities in the use of carotid revascularization.

Health related quality of life of the patients after transient ischaemic attack: is carotid endarterectomy (CEA) or carotid artery stenting (CAS) more influential?

Although randomized trials have proven the benefit of revascularization with the use of carotid endarterectomy (CEA) or stenting (CAS) for appropriate patients, health care purchasers increasingly look beyond clinical outcome toward measures of health-related quality of life (HRQoL) in apportioning limited resources. 36 patients after TIA participated in this study. One group (n=18) had undergone CEA, whereas the second group (n=18) had undergone CAS. Both groups were matched according to age and sex. The Short Form 36 (SF-36) was used to assess the differences in patient-perceived HRQoL in two groups of patients who had suffered minor cerebral ischemic events. No significant difference in health profile between the CEA and CAS was detected for the eight SF-36 domains. However, the CEA group rated a significantly improved change in general health after one year compared with the CAS group (p&lt;0.001). A greater proportion of the CEA group comparing to the CAS group thought their treatment had been successful and that their health had been improved (p&lt;0.001). Both groups shared the same level of anxiety over potential future cerebral ischemic events (p=0.3). Patients' perception of HRQoL measured by the SF-36 domains was almost identical between the CEA and CAS apart from a small but significant improvement in self-reported overall health in the CEA group after one year follow up. HRQoL outcome measures may be of value in future clinical trials of cerebral revascularization to compare the effectiveness of carotid revascularization with the particular method of operation.

Outcome Analysis of Carotid Cross-Clamp Intolerance during Carotid Endarterectomy under Locoregional Anesthesia

To analyze the predictors and describe the outcomes of cross-clamp intolerance (CCI) and the results of the use of carotid endarterectomy (CEA) with shunting or a shift strategy to immediate carotid artery stenting (CAS) in this setting. Between January 2008 and December 2015, 385 patients were elected for single-sided, isolated CEA under locoregional anesthesia. In case of CCI, CEA with shunt was used selectively, whereas indication to immediate conversion to CAS was the immediate onset and severe persistent deterioration of the neurologic status, and/or local technical difficulties to perform endarterectomy. Primary outcome was prevention of death and all early (<30days) perioperative cerebrovascular events. We treated 169 (43.9%) symptomatic lesions; urgent (≤48hours) intervention was performed in 85 (22.1%) cases. Carotid CCI occurred in 45 (11.7%) patients. CEA with shunt was used in 16, whereas CAS in 27 (7.0%, 2 refused further treatment). Multivariable analysis identified hypertension (odds ratio [OR]: 2.93, 95% confidence interval [CI]: 1.01-8.52; P=0.049) and symptomatic lesions (OR: 2.34, 95% CI: 1.11-4.93; P=0.025) as significant predictors of CCI. In-hospital mortality rate was 0.5%; none occurred in CCI group. Postoperative cerebrovascular event rate was 2.3% (n=9). At multivariable analyses, only CCI (OR: 6.60, 95% CI: 1.65-26.36; P=0.008) was significantly associated with postoperative cerebrovascular events, with no significant different clinical outcomes between CEA and CAS. Hypertension and symptomatic carotid stenosis were significant predictors of CCI, which was found to be predictive for postoperative cerebrovascular events. In selected patients with CCI, CAS had satisfactory, similar results of CEA.

Management of carotid stenosis in women

Specific guidelines for management of cerebrovascular risk in women are currently lacking. This study aims to provide a consensus expert opinion to help make clinical decisions in women with carotid stenosis. Proposals for the use of carotid endarterectomy (CEA), carotid stenting (CAS), and medical therapy for stroke prevention in women with carotid stenosis were provided by a group of 9 international experts with consensus method. Symptomatic women with severe carotid stenosis can be managed by CEA provided that the perioperative risk of the operators is low (<4%). Periprocedural stroke risks may be increased in symptomatic women if revascularization is performed by CAS; however, the choice of CAS vs CEA can be tailored in subgroups best fit for each procedure (e.g., women with restenosis or severe coronary disease, best suited for CAS; women with tortuous vessels or old age, best suited for CEA). There is currently limited evidence to consider medical therapy alone as the best choice for women with neurologically severe asymptomatic carotid stenosis, who should be best managed within randomized trials including a medical arm. Medical management and cardiovascular risk factor control must be implemented in all women with carotid stenosis in periprocedural period and lifelong regardless of whether or not intervention is planned. The suggestions provided in this article may constitute a decision-making basis for planning treatment of carotid stenosis in women. Most recommendations are of limited strength; however, it is unlikely that new robust data will emerge soon to induce relevant changes.

総頚動脈起始部狭窄症に対する経大腿動脈アプローチによるステント留置術の2例

Stenosis of the proximal common carotid artery (pCCA) is rare. It is difficult to treat by surgical or endovascular revascularization, and there are few published cases. In rare cases, the pCCA stenosis is concomitant with stenosis of the internal carotid artery (ICA) and it can be difficult to determine which is the truly symptomatic lesion in such cases. Current treatment of pCCA stenosis includes alternative vascular access routes like the combined use of carotid endarterectomy and retrograde angioplasty with or without stenting. We report the method of percutaneous transfemoral approach for pCCA revascularization with stent supported by two guidewires. The guiding catheter is placed proximal to the ostium of the narrow pCCA with a co-axial method. First, the balloon type embolic protection device is introduced in the ICA to prevent embolic stroke and after, a 0.014 inch supporting stiff guidewire is carefully passed through the pCCA stenosis and placed in the external carotid artery (ECA). Finally, a balloon-expanding stent is advanced to the pCCA stenosis guided by both the protection device wire positioned in the ICA, and the supporting microguidewire positioned in the ECA. The two-guidewire technique provides a safer and more stable condition for the procedure, increasing its success rate. We discuss the etiology and endovascular treatment of the proximal carotid artery stenosis, and review the literature.

Trends in Carotid Endarterectomy, Carotid Angioplasty, and Stenting

Use of carotid endarterectomy (CEA) has waxed and waned since the 1980s in response to studies that showed benefits only in carefully selected

Changes in the Use of Carotid Revascularization Among the Medicare Population

It remains unknown if the increasing use of carotid artery stenting (CAS) has caused a change in the population-based use of carotid endarterectomy (CEA). We sought to examine national trends in carotid revascularization. Retrospective cohort study. Academic research. All Medicare beneficiaries (MCBEs) between January 1, 1998, through December 31, 2004. We examined the frequency of CEA and CAS using Current Procedural Terminology codes for CEA, peripheral stent insertion, and cerebrovascular disease. To exclude patients who underwent stenting of a peripheral artery other than the carotid artery, we excluded all patients with a primary diagnostic code for peripheral vascular disease. We identified 134 194 claims for carotid revascularization (9386 claims for CAS and 124 808 claims for CEA). The overall incidence of carotid revascularization procedures decreased slightly between 1998 and 2004, from 388.1 to 345.8 procedures per 100 000 MCBEs (11% decrease, P < .02). Between 1998 and 2004, the incidence of CEA decreased from 373.4 to 309.3 procedures per 100 000 MCBEs (17% decrease, P < .01), while the incidence of CAS increased from 14.6 to 36.4 procedures per 100 000 MCBEs (149% increase, P < .01). While rates of carotid revascularization in the Medicare population slightly decreased between 1998 and 2004, the use of CAS dramatically increased. Whether this represents a substitution of CAS for CEA vs a broadening of indications for carotid revascularization using CAS is unknown but is of interest to patients and third-party payers and requires future investigation.

Pathophysiology and therapeutic strategies in the management of stroke: An update

Strokes, or brain attacks, which occur due to an interruption of blood flow in discrete regions of the brain, are a major cause of death. Stroke is the third leading cause of death and disability in developed nations. The complex pathophysiology of this medical problem includes excitotoxicity mechanisms, inflammatory pathways, oxidative damage and ionic imbalances. The final event is the ischemic neuronal death which results in an irreversible loss of the neuronal function. Recently, significant therapeutic advances have been made which include use of carotid endarterectomy, thrombolytics, anticoagulant therapy, antiplatelet agents, neuroprotective agents, and treating associated risk factors such as hypertension and hyperlipemia. However, in spite of the significant development in these areas of stroke research, none of the available therapeutic options are curative in that they can reduce the burden of stroke. This article briefly summarizes the status of advances made in order to understand the neurobiology of stroke and provide insight into the therapeutic strategies that could be developed for the effective management of ischemic stroke.

Ｎｅａｒ Ｏｃｃｌｕｓｉｏｎに対するＣａｒｏｔｉｄ Ｅｎｄａｒｔｅｒｅｃｔｏｍｙ―ＭＲＩプラーク性状評価と術後内頸動脈の開存性について―

The use of carotid endarterectomy (CEA) for near occlusion (NO) of the internal carotid artery (ICA) has not been evaluated with respect to the diagnostic procedures required, the risks, the appropriate timing, or the benefit of revascularization. Some reports note that the operative risks of CEA in NO patients and in some atherosclerotic total occlusion (TO) patients are not greater than those in patients with ordinary ICA stenosis. However, it is generally accepted that the rate of restenosis after CEA in NO/TO is very high. In the treatment of atherosclerotic ICA stenosis, it is important to consider not only the stenosis rate but also the plaque characteristics; in recent years, many reports that have used these criteria have demonstrated the usefulness of carotid MRI. We report the therapeutic results of CEA done in cases with NO/TO, particularly with respect to the relationship between the MRI plaque findings and the postoperative patency of the distal ICA. Seven CEAs were done in carotid NO/TO cases between March 2003 and October 2005 in our hospital. The morphology of the ICA stenosis and the characteristics of the carotid plaque were evaluated with digital subtraction angiography (DSA) and carotid black-blood (BB) MRI, respectively. Plaques were excised as single masses during CEA and then processed for histology. One asymptomatic case with de novo small infarction was confirmed on diffusion-weighted MRI images. In our study, neither hemorrhagic complications nor hyper-perfusion syndromes were observed. The overall safety of CEA for NO/TO was acceptable. The BB-MRI findings on T1-weighted images included: an extremely high signal in 3 cases; a slightly high signal in 2 cases; an isosignal in 1 case; and a low signal in 1 case. On histology, there was massive fresh intra-plaque hemorrhage (IPH) in 3 cases, subacute IPH in 1 case, chronic IPH in 1 case, and recanalization of occlusive thrombosis in 2 cases. One patient had asymptomatic thrombotic occlusion. Another patient had a poorly dilated distal ICA. These patients' pre-operative DSA showed NO with a string-like lumen, the BB-MRI revealed iso/low signals and histology demonstrated chronic IPH/recanalization. CEA for “chronic” NO/TO is of little benefit, since satisfactory post-operative patency of the distal ICA cannot be obtained. BB-MRI appears to be a useful modality for differentiating “acute” from “chronic” NO/TO.

Sydenham Society: racial variations in carotid endarterectomy

Dr. Halm's work indicates that in certain well-characterized clinical situations, supported by a high level of evidence, carotid endarterectomy in good hands conducted in good hospitals reduces future stroke risk with very favorable “number needed to treat” values. The main question for my presentation is, “Are we referring enough patients for this procedure?” An answer to that question, involving race and use of carotid endarterectomy, relies on a rigorously defined method for appropriateness of this procedure to determine if underuse prevails.

Prevention of Stroke Recurrence

Stroke recurrence can be reduced substantially by intervention with the appropriate stroke preventive(s). Control of blood pressure, use of one of the antiplatelet agents aspirin, aspirin plus extended (modified)-release dipyridamole, or clopidogrel, administration of warfarin for patients with atrial fibrillation and high-risk profiles for stroke, and use of carotid endarterectomy in patients with high grades of symptomatic carotid artery stenosis are all proven therapies for prevention of stroke recurrence. Newer therapies to reduce the risk of infection and inflammation promise to further reduce the risk of first and recurrent stroke and are undergoing testing. In this article we review standard and more novel means to prevent stroke recurrence.

Revisiting the appropriateness of carotid endarterectomy.

In the 1980s, carotid endarterectomy was controversial because proof of efficacy was lacking, complication rates were high, and one third of cases were reported to be inappropriate. Since publication of several randomized controlled trials (RCTs), rates of carotid endarterectomy have doubled nationwide. This study assesses the appropriateness and use of carotid endarterectomy since publication of the RCTs. Using the literature, we developed a list of 1557 mutually exclusive indications for carotid endarterectomy and asked a panel of national experts to rate the appropriateness of each indication using the RAND methodology. We used these ratings to assess appropriateness in a sample of 2124 patients who underwent the procedure in 1997 to 1998 in 6 hospitals. We also analyzed the reasons for the procedure and rates of death, stroke, and myocardial infarction within 30 days of surgery. Overall, 84.9% of operations were done for appropriate reasons, 4.5% for uncertain reasons, and 10.6% for inappropriate reasons. Among procedures considered inappropriate, the most common reasons were high comorbidity (46.6%) and minimal stenosis (27.1%). Overall, 72.5% were asymptomatic, 17.4% had a carotid transient ischemic attack, and 10.1% had a stroke. The 30-day rate of death or stroke was 5.47% for symptomatic patients and 2.26% for asymptomatic patients. Among patients having combined carotid and coronary artery bypass graft surgery, the rate was 10.32%. The complication rate in asymptomatic patients with high comorbidity was 5.56%. Since the RCTs, rates of overuse appear to have fallen considerably, although they are still significant. A major shift has occurred toward operating on asymptomatic patients. Although overall complication rates were low, rates among asymptomatic patients with high comorbidity exceeded recommended thresholds.

Identifying Risk Factors for Stroke in Asymptomatic Carotid Stenosis

The use of carotid endarterectomy (CEA) in asymptomatic carotid-artery stenosis is controversial. Although a large, randomized, prospective study of

Gender differences in the treatment of cerebrovascular disease.

Previous studies have shown that women receive fewer invasive procedures for the treatment of coronary artery disease than men, but gender differences in cerebrovascular disease have not been well studied. Our objective was to explore differences in the treatment of stroke between men and women. Secondary database analyses. We examined the use of carotid endarterectomy in a nationally representative sample of Medicare enrollees aged 65 to 84, hospitalized for a principal diagnosis of stroke in 1992, the "all strokes group". We also studied a subgroup of patients, the "carotid disease subgroup", admitted with a principal diagnosis of precerebral arterial occlusion and stenosis or transient cerebral ischemia. We determined rates of carotid endarterectomy for the all strokes group within gender and age groups and calculated corresponding female-to-male relative risks (RR) and 95% confidence intervals (CI). We also performed similar analyses for the carotid disease subgroup. We then used logistic regression to estimate the relative risk of use of carotid endarterectomy for women, controlling for age and comorbidity. The all-strokes group consisted of 3,356 women and 2,927 men, of whom 1,009 women and 990 men were in the carotid disease subgroup. The overall age-adjusted female-to-male relative risk of undergoing carotid endarterectomy for those aged 65 to 84 was 0.69 (95% CI, 0.64-0.74) in the all strokes group and 0.77 (95% CI, 0.72-0.82) in the carotid disease subgroup. In both analyses, the RR became more pronounced with increasing age. In the all strokes group, for example, the RR was 0.80 (0.70-0.92) for those aged 65 to 69 and 0.39 (0.32-0.48) for those aged 80 to 84. The RR for the all strokes group remained similar in magnitude even after controlling for comorbidity (RR, 0.63 and 95% CI, 0.59-0.70). We conclude that women hospitalized for strokes undergo fewer carotid endarterectomies than men. Further studies are needed to examine the reasons for and implications of this gender difference.

The causes and risk of stroke in patients with asymptomatic internal-carotid-artery stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators.

The causes of stroke in patients with asymptomatic carotid-artery stenosis have not been carefully studied. Information about causes might influence decisions about the use of carotid endarterectomy in such patients. We studied patients with unilateral symptomatic carotid-artery stenosis and asymptomatic contralateral stenosis from 1988 to 1997. The causes, severity, risk, and predictors of stroke in the territory of the asymptomatic artery were examined and quantified. The risk of stroke at five years after study entry in a total of 1820 patients increased with the severity of stenosis. Among 1604 patients with stenosis of less than 60 percent of the luminal diameter, the risk of a first stroke was 8.0 percent (1.6 percent annually), as compared with 16.2 percent (3.2 percent annually) among 216 patients with 60 to 99 percent stenosis. In the group with 60 to 99 percent stenosis, the five-year risk of stroke in the territory of a large artery was 9.9 percent, that of lacunar stroke was 6.0 percent, and that of cardioembolic stroke 2.1 percent. Some patients had more than one stroke of more than one cause. In the territory of an asymptomatic occluded artery (as was identified in 86 patients), the annualized risk of stroke was 1.9 percent. Strokes with different causes had different risk factors. The risk factors for large-artery stroke were silent brain infarction, a history of diabetes, and a higher degree of stenosis; for cardioembolic stroke, a history of myocardial infarction or angina and hypertension; for lacunar stroke, age of 75 years or older, hypertension, diabetes, and a higher degree of stenosis. The risk of stroke among patients with asymptomatic carotid-artery stenosis is relatively low. Forty-five percent of strokes in patients with asymptomatic stenosis of 60 to 99 percent are attributable to lacunes or cardioembolism. These observations have implications for the use of endarterectomy in asymptomatic patients. Without analysis of the risk of stroke according to cause, the absolute benefit associated with endarterectomy may be overestimated.