Indications for carotid endarterectomy

Stroke is a major health problem in the United States. Carotid endarterectomy has been performed to prevent stroke in symptomatic and asymptomatic patients with carotid atherosclerosis. The rationale for this approach has been questioned recently and several studies were begun to determine the proper role of surgery. The initial results from studies of symptomatic patients demonstrate that surgery is urgently indicated if stenosis is at least 70%, but not if it is less than 30%. Patients with intermediate amounts of stenosis are still being evaluated. Early evidence suggests that surgery is not indicated for asymptomatic patients, but two major trials are still in progress. Surgeons performing this procedure must demonstrate low perioperative morbidity and mortality. In addition, the use of ultrasound as a screening procedure is being re-evaluated. We suggest rapid referral and evaluation of symptomatic patients with angiography, and treatment of asymptomatic patients with aspirin.