Carotid endarterectomy: why question it now?

Carotid endarterectomy has been accepted widely as an important stroke-prevention tool since the 1950s, in spite of the lack of any proof of its efficacy in randomized, controlled clinical trials in either symptomatic or asymptomatic patients. While surgery for asymptomatic carotid disease always has been controversial, the indications and benefits of carotid endarterectomy in symptomatic patients now are being questioned also, although the available evidence suggests that the operation, when performed in expert hands, reduces the incidence of subsequent strokes in patients with minor, carotid-territorial ischaemic events and significant ipsilateral carotid disease. (A morbidity and mortality rate of more than 3% is unacceptable, and hence the procedure should be undertaken only by those who are skilled in its performance). For each patient, a decision has to be made as to whether the potential reduction of the risk of stroke outweighs the immediate surgical risk of stroke or death. Some large, expensive and important randomized clinical trials are either proposed or under way in North America and Europe to evaluate the precise role of carotid endarterectomy in the prevention of strokes. The basis for the current questioning of carotid endarterectomy and the rationale for these trials are addressed in this review.