[Carotid surgery. Assessment and current problems]

Every year in France, approximately 12,000 strokes are due to stenosis of an extracranial internal carotid artery. One third of these patients are dead and one third have disabling sequelae at 6 months follow up, emphasizing the need for prophylactic therapy. The efficacy of antiaggregants and the value of correction of risk factors have been proven for a decade or more, whereas carotid artery surgery has for a long time been a subject for debate because of its perioperative complications and the lack of consensus on its indications. Happily, several recent multicenter studies have provided positive evidence of its value. After a transient ischemic accident or mild stroke, patients with a stenosis of more than 70% should be operated upon, in the absence of any local or general contraindication and if the surgical team has a record of a less than 5% cumulated mortality and neurologic morbidity. For asymptomatic severe stenotic lesions, it appears justified to operate on those occluding by more than 80%, in patients presenting the same characteristics and if the surgical team's incidence of complications is less than 3%. Although arguments exist for operating upon a severe carotid artery stenosis associated with vertebrobasilar insufficiency or severe stroke without major cerebral impairment, these indications have not been evaluated by multicenter trials and each case should be treated individually.