[Current status of carotid surgery]

Introduced in the fifties, reconstructive surgery of the carotid arteries has undergone an extensive development in Europe and the United States. Prospective randomized multicentric clinical trials have clearly demonstrated its effectiveness in stroke prevention for both symptomatic and asymptomatic patients with tight carotid stenosis. The diminution of relative risk secondary to surgery is at least 40%; it is 80% for major ipsilateral stroke. There is no benefit if the vessel narrowing is less than 30%. For the 30 to 70% stenosis a benefit has not yet been clearly established. The prophylactic effect of carotid surgery is highly dependent of a low postoperative morbidity. The 30 day stroke plus death rate should not exceed 3% for asymptomatic patients and 5% for symptomatic patients. Postoperative morbidity-mortality has greatly improved over the last twenty years. Several factors are involved; the main improvement may be related to better surgical technique assessed by intra-operative angiographic control rather than the many methods of monitoring or cerebral protection. Ten years patency of arterial reconstruction is greater than 90%. Stroke protection is effective since the annual rate of cerebral events in an operated population is about 2% while it is about 10% in a control population. Inversely, late mortality is still high, primarily due to cardiac disease.