The case against surgery for asymptomatic carotid stenosis.

Chambers, Brian R.; Norris, John W.

doi:10.1161/01.str.15.6.964

Cited by 153 publications

(28 citation statements)

References 21 publications

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“…For asymptomatic patients, the criteria should be even more stringent. Chambers and Norris 10 have suggested that the annual stroke rate for asymptomatic patients must exceed 5% for carotid reconstruction to be justified.…”

Section: Resultsmentioning

confidence: 99%

Carotid endarterectomy. Clinical results in a community-based teaching hospital.

Friedmann

Garb

Berman

et al. 1988

Stroke

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Since 1971, 6$8 consecutive carotid endarterectojnies were performed in 612 patients in a commun.ity-based teaching hospital by 16 surgeons; 82% of the procedures were performed in patients who had suffered a transient ischemic attack, amaurosis fugax, or a previous stroke. Seven patients (1%) died, five of perioperative stroke and two of myocardial infarction. Thirty-one patients suffered a perioperative stroke (4.5% of the 688 endarterectomies); 20 patients (2.9% of 688) were left with moderate to severe neurologic deficits. The combined mortality/major neurologic deficit morbidity rate (number of patients -s-number of endarterectomies) is 3.2%. Both operative mortality and morbidity have progressively declined in successive 5-year periods, with no deaths and a 2.7% stroke rate in 148 endarterectomies performed after 1984. Our results indicate that carotid endarterectomy as practiced in a community-based teaching hospital can be performed without excessive risk. (Stroke 1988; 19:1323-1327) D eath and disability related to stroke remain one of the most important public health problems in the United States today. Even though the stroke rate is declining by approximately 6% annually, more than 150,000 Americans die each year of stroke. Many of the estimated 2 million people disabled by stroke are in their economically productive years. The total cost to the nation was estimated at 12.8 billion dollars in 1987. ' The role of carotid endarterectomy in the prevention of stroke has come under increasing scrutiny. It is estimated that more than 100,000 carotid endarterectomies are performed annually in the United States, at a cost in excess of 1.2 billion dollars. 2Many surgeons have achieved excellent results with low morbidity and mortality rates, and many centers also report excellent results. However, the overall results of surgery may be substantially worse than those reported in the best series. Communitybased studies appear to indicate that morbidity and mortality rates, although declining, are still excessive for some groups of patients.3 Because of allegations of high morbidity and mortality rates, all institutions in which carotid endarterectomy is performed have been challenged to review their results. Subjects and MethodsWe reviewed the results of 688 consecutive carotid endarterectomies performed at Baystate Medical Center from 1971 to the present. Virtually all patients were operated on under general anesthesia; shunting was routinely used, as was heparin anticoagulation. Primary closure of the arteriotomy was most commonly employed, although patch closures with autogenous vein or synthetic materials were occasionally used. Endarterectomy was performed under local or regional anesthesia extremely rarely, and other types of monitoring such as intraoperative electroencephalography or cerebral blood flow measurements were not used. Completion angiography was rarely used, and intraoperative ultrasonic, imaging was not employed. ResultsThere were 688 carotid endarterectomies performed in 612 patients; 76 p...

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Section: Resultsmentioning

confidence: 99%

Carotid endarterectomy. Clinical results in a community-based teaching hospital.

Friedmann

Garb

Berman

et al. 1988

Stroke

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“…However, the failure of the external carotid-internal carotid bypass operation to prevent stroke 146 and the absence of clinical trial data provoked challenges about the safety and efficacy of CEA. 147 Subsequently, in the late 1980s and early 1990s, 6 randomized clinical trials established the efficacy of CEA plus aspirin compared with aspirin alone in preventing stroke in patients with atherosclerotic carotid bifurcation stenosis. 18,19,22,23,37,38,148,149 CEA is now the standard revascularization therapy against which CAS must be compared.…”

Section: Historical Perspectivementioning

confidence: 99%

ACCF/SCAI/SVMB/SIR/ASITN 2007 Clinical Expert Consensus Document on Carotid Stenting

Bates¹,

Babb²,

Cates³

et al. 2007

Vasc Med

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This document has been developed by the American College of Cardiology Foundation (ACCF) Task Force on Clinical Expert Consensus Documents (CECD), and was cosponsored by the Society for Cardiovascular Angiography and Interventions (SCAI), the Society for Vascular Medicine and Biology (SVMB), the Society of Interventional Radiology (SIR), and the American Society of Interventional & Therapeutic Neuroradiology (ASITN). It is intended to provide a perspective on the current state of carotid artery stenting (CAS). The CECDs are intended to inform practitioners, payers, and other interested parties of the opinion of the ACCF and cosponsors concerning evolving areas of clinical practice and/or technologies that are widely available or new to the practice community. Topics chosen for coverage by expert consensus documents are so designed because the evidence base, the experience with technology, and/or the clinical practice are not considered sufficiently well developed to be evaluated by the formal American College of Cardiology/ American Heart Association (ACC/AHA) practice guidelines process. Often the topic is the subject of ongoing investigation. Thus, the reader should view the CECD as the best attempt of the ACCF and the cosponsors to inform and guide clinical practice in areas where rigorous evidence may not be available or the evidence to date is not widely accepted. When feasible, CECDs include indications or contraindications. Some topics covered by CECDs will be addressed subsequently by the ACC/AHA Practice Guidelines Committee.The Task Force on CECDs makes every effort to avoid any actual or potential conflicts of interest that might arise as a result of an outside relationship or personal interest of a member of the writing panel. Specifically, all members of the writing panel are asked to provide disclosure statements of all such relationships that might be perceived as real or potential conflicts of interest to inform the writing effort. These statements are reviewed by the parent task force, reported orally to all members of the writing panel at the first meeting, and updated as changes occur. The relationships with industry information for writing committee members and peer reviewers are published in the appendices of the document.

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“…Carotid endarterectomy, therefore, appears to be an unattractive alternative to medical management in asymptomatic patients, particularly since they are likely to experience TIAs prior to a completed stroke. 26 Despite a large body of data on carotid endarterectomy for symptomatic patients, proof of efficacy is still wanting. The ability to standardise pooled data from many centres exists and warrants undertaking a prospective study.…”

Section: Risks and Benefitsmentioning

confidence: 99%

Risks of carotid endarterectomy. Toronto Cerebrovascular Study Group.

Wilkins¹

1986

Stroke

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SUMMARY An objective, retrospective review of 358 carotid endarterectomies performed in the neurosurgical teaching units of the University of Toronto in the year 1982 demonstrated a perioperative stroke rate of 3.9% and a death rate of 1.5%.Most (82%) surgical neurological complications occurred after the immediate post-operative period (24 hours). This high incidence of delayed stroke suggests that most perioperative strokes are embolic rather than hemodynamic. Careful operative technique and the use of anticoagulants and antiplatelet agents may be more important in preventing postoperative deficits than intraoperative monitoring and intraluminal shunting.Our figures and those of current published data indicate that a 5-6% combined morbidity and mortality should be expected in carotid endarterectomy. These data are critical both to decision making with the individual patient as well as in the planning of future carotid surgery trials. Stroke Vol 17, No 5, 1986 EVALUATION OF CAROTID ENDARTEREC-TOMY for stroke prevention requires realistic expectations about perioperative morbidity and mortality. Published stroke and death rates vary from less than !%,'• 2 to almost 25%. 3 Surgeons tend to report lower figures, 4 " 8 while higher rates emerge from citywide 39 or multi-centre experience, 10 usually reported by neurologists.Although carotid endarterectomy as an effective means of stroke prevention has been practiced for years, its efficacy has never been properly evaluated." The need for a prospective study using modern methodology is long overdue. Feasibility and study design require knowledge of expected stroke and death rates for a relatively large group of surgeons.This study reports results in a large consecutive series of procedures performed in the Toronto teaching hospitals and differs from most previous studies with respect to the objective manner in which data was collected and analysed. in the study. Consecutive cases of carotid endarterectomy in the calendar year 1982 were reviewed. Protocols were devised which identified cases by study, number only, omitting identity of the patient, surgeon and hospital. MethodsA study coordinator (MCZ) experienced in stroke research, transferred relevant information from the hospital charts to data entry forms using pre-determined definitions of carotid stroke and transient ischemic attack (TIA).Questionable or missing entries were reviewed by the principal investigators (a neurosurgeon and a neurologist) who requested additional information as necessary. The principal investigators remained "blind" and only the study coordinator had direct access to hospital charts. Participating neurosurgeons agreed to protocol design and authorised chart review on their own cases. They did not review data entry forms, nor did they have any input into their completion.Neurological deficits lasting more than 24 hours were classified as cerebral infarction, providing the corresponding computed tomography (CT) did not show evidence of hemorrhage. The designation of cerebral infarcti...

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The case against surgery for asymptomatic carotid stenosis.

Cited by 153 publications

References 21 publications

Carotid endarterectomy. Clinical results in a community-based teaching hospital.

Carotid endarterectomy. Clinical results in a community-based teaching hospital.

ACCF/SCAI/SVMB/SIR/ASITN 2007 Clinical Expert Consensus Document on Carotid Stenting

Risks of carotid endarterectomy. Toronto Cerebrovascular Study Group.

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