Carotid Endarterectomy

Carotid endarterectomy has been performed for almost 40 years. Controversy surrounding this procedure largely has been due to the variability in results experienced by different surgeons. Evidence that carotid endarterectomy can cause a 65% to 83% reduction in the risk of stroke recently has been established by two prospective randomized protocols. Results of the North American Symptomatic Carotid Endarterectomy Trial (United States) and the UK Medical Research Council Carotid Surgery Trial (Europe) are promising. Because stroke ranks as the third most common cause of death in the United States, the potential impact of carotid endarterectomy in improving longevity and quality of life is obvious. New strokes occur in approximately 500,000 Americans yearly. One third of those patients die within 30 days of onset, and one half of the remainder suffer significant disability. This article reviews the history of carotid endarterectomy, invasive and noninvasive diagnostic techniques, the importance of clinical classification of carotid occlusive disease, indications for surgery, and operative technique. The necessity for intraluminal carotid shunting for cerebral protection as well as operative complications are reviewed. Preoperative and long-term functional results are quantified, and a protocol for the management of asymptomatic carotid stenosis is presented. The management of acute stroke, contralateral occlusion, and recurrent stenosis is covered in this comprehensive review.