Results of carotid endarterectomy: the gold standard for carotid repair.

Carotid endarterectomy (CEA) generated substantial controversy during the mid-1980s because of the large number of operations that were being performed in the United States compared with other industrialized nations, the emergence of antiplatelet therapy as a possible alternative to surgical treatment for carotid disease, and the lingering question about whether the safety of CEA in published reports actually is attained at the thousands of hospitals in which it is performed. Several influential randomized trials now have validated the efficacy of CEA for stroke prevention in symptomatic patients having at least 50% carotid stenosis, as well as in asymptomatic patients with higher-grade lesions and no surgical contraindications. It must be remembered, however, that the surgeons who participated in these trials were vetted on the basis of acceptable stroke and mortality rates that were documented for their previous experience with CEA. A number of statewide and Medicare audits have shown that, although the complication rates of CEA appear to have declined to some extent during the past decade, they still exceed the standards established by the randomized trials in many geographic areas and often assume an inverse relationship to the annual volume of CEAs performed at hospitals and by individual surgeons. Although the indications for CEA never have been more clearly known or widely accepted than they are today, its designation as the gold standard for the management of patients meeting these criteria continues to depend on outcome assessment and quality control at the local level. Furthermore, these measures will be just as necessary for carotid balloon angioplasty and intraluminal stenting, because any competitive form of treatment legitimately should receive the same scrutiny as CEA.