[Surgery of carotid stenosis and prevention of cerebral infarction]

In 1983, the author, relating his personal experience, as well as those of other authors, presented a critical analysis of indications and results of surgical treatment for carotid artery stenosis in order to prevent stroke. The actual experience of the author is based on for 142 patients operated on from 1st January 1982 to 31st December 1986. This study includes 32 stage 0 (asymptomatic) patients, 95 stage I (transient) patients, and 15 stage IIIa (slight deficit) patients. The immediate mortality rate has been 2.1% with a rate of severe morbidity of 1.4%. The 5 year survival rate has been 72.3% decreasing fairly regularly from 90% for the first year. The conclusions of this study and other published at the same time in the literature were that there was a category of high-risk patients with over 70% stenosis, especially those with an history of transient ischemic attack. But unfortunately no randomized work was available for supporting these conclusions. Lately, two randomized studies have been published, the first one in Europe called ECST (European Carotid Surgery Trial), and the second one in North America called NASCET (North American Symptomatic Endarterectomy Trial). The European Trial based on 2,518 patients showed that for 778 patients with a carotid stenosis between 70% and 99% and a history of a transient ischemic attack the cumulative risk of any ipsilateral stroke at 3 years was 10.3% for the surgical group and 16.8% for the medical group. The North American Trial is still more accurate. For 659 patients in the same conditions, the risk of any ipsilateral stroke at 2 years is 9% for the surgical group and 26% for the medical group. Those two studies make clear that carotid endarterectomy significatively lowers the risk of severe or lethal cerebral stroke in the patient group with a stenosis of ICA higher than 70% and a TIA. Nevertheless, there is no modification of the total mortality, of whose the first cause is coronary disease. Other studies are in progress in order to appreciate the results of surgery for stenosis between 30% and 69% and for asymptomatic patients.