Is there still a place for carotid endarterectomy?

Carotid endarterectomy is a controversial procedure. Despite the increasing incidence of its performance, there have been as yet no prospective randomised trials which have conclusively shown its benefits for patients with carotid artery atherosclerosis. Until the results of such studies become available, a rational approach to the estimation of stroke risk in these patients can be based on an understanding of their carotid plaque morphology. Over the past 4 years we have examined plaque morphology with a B-mode duplex scanner and have been able to categorise the degree of heterogeneity of plaques into 4 types depending on the degree of plaque echolucency. We have shown good correlation between the preoperative plaque type and the operation specimen. Furthermore, we have found that the risk of symptom development correlates with the development of a more echolucent plaque. Finally, while plaque heterogeneity may be a good predictor of the risk of embolism from the plaque, other deleterious factors such as hypertension may determine the severity of the ensuing neurological event. The approach in our unit has been to operate on symptomatic patients with demonstrated high grade or heterogeneous carotid artery atherosclerosis appropriate to the patient's symptoms. We have found that most asymptomatic patients have subcritical stenoses and dense homogeneous plaques, and we treat these conservatively. On the other hand, surgery is recommended for asymptomatic patients with high grade stenoses and heterogeneous plaques. We have been able to follow this policy with a morbidity and mortality of 2.6% and 1.0% respectively.