The purpose of this study was to evaluate the indications for carotid endarterectomy (CEA) in the authors' geographic area and compare responses of vascular surgeons and neurologists. Results were also compared with the recommendations of the Rand panel.
Vascular surgeons and neurologists agreed that multiple transient ischemic attacks (TIA) in patients receiving medical treatment and in those with crescendo ischemic attacks were appropriate indications for endarterectomy. However, surgeons favored CEA significantly more (p < 0.0001) than neurologists for other symptomatic patients. No agreement could be found between surgeons and neurologists for endarterectomy in patients with asymptomatic carotid disease.
Although a national panel of experts has identified appropriate indications for CEA, the authors' medical community (Eastern Pennsylvania) has significant variations when responses of vascular surgeons and neurologists are compared. Therefore, patient treatment depends mainly on the referral patterns of the primary care physician. Further prospective studies are required to achieve unanimity regarding indications for this operation.
Get full access to this article
View all access options for this article.
References
1.
Rosenthal D., Borrero E., Clark MD, et al: Carotid endarterectomy after reversible ischemic neurologic deficit or stroke: Is it of value?J Vasc Surg8:527-534, 1988.
2.
Feussner JR, Matchar DB: When and how to study the carotid arteries. Ann Intern Med109:805-818, 1988.
3.
Fields WS: Medical therapy for transient ischemic attack and stroke. In: Current Therapy in Vascular Surgery, ed. by Ernst CB, Stanley JC.Philadelphia: Decker, 1987, pp 5-7.
4.
Sumner DS: Asymptomatic carotid artery atherosclerosis. In: Current Therapy in Vascular Surgery, ed. by Ernst CB, Stanley JC.Philadelphia: Decker, 1987, pp 10-13.
5.
Weibers DO, et al: Mayo Asymptomatic Carotid Endarterectomy Study Group. Effectiveness of carotid endarterectomy for asymptomatic carotid stenosis: Design of a clinical trial. Mayo Clin Proc64:897-904, 1989.
6.
Leape LL, Park RE, Solomon DH, et al: Relation between surgeons' practice volumes and geographic variation in the rate of carotid endarterectomy. N Engl J Med10:653-657, 1989.
7.
Chassin MR, Kosecoff J., Park RE, et al: Does inappropriate use explain geographic variations in the use of health care services? A study of three procedures. JAMA258:2533-2537, 1987.
8.
Winslow CM, Solomon DH, Chassin MR, et al: The appropriateness of carotid endarterectomy. N Engl J Med318:721-727, 1988.
9.
Merrick NJ, Fink A., Brook RH, et al: Indications for selected medical and surgical procedures—a literature review and ratings of appropriateness. Santa Monica, CA: Rand Corp., 1986 (Publication R-3204/6).
10.
Davis SM, Gates PC: Carotid endarterectomy: Why question it now?Med J Aust150:28-30, 1989.
11.
Grotta JC: Current medical and surgical therapy for cerebrovascular disease. N Engl J Med317:1505-1506, 1987.
12.
Goldstone J. , Moore WS: A new look at emergency carotid artery operations for the treatment of cerebrovascular insufficiency. Stroke9:599-602, 1978.
13.
Wolf PA, Kannel WB, Sorlie P., et al: Asymptomatic carotid bruit and risk of stroke, the Framingham study. JAMA245:1442-1445, 1981 .
14.
Chambers BR , Norris JW: Outcome in patients with asymptomatic neck bruits. N Engl J Med315:860-865, 1986.
15.
AbuRahma AF , Robinson PA: Prospective clinicopathophysiologic follow-up study of asymptomatic neck bruit. Am Surg56:108-113, 1990.
16.
Moneta GL, Taylor DC, Nicholls SC, et al: Operative versus nonoperative management of asymptomatic high-grade internal carotid artery stenosis: Improved results with endarterectomy. Stroke18:1005-1010, 1987.
17.
Martin NA, Hadley MN, Spetzler RF, et al: Management of asymptomatic carotid atherosclerosis. Neurosurg18:505-513, 1986.
18.
Barnes RW, Liebman PR, Marzalek PB, et al: The natural history of asymptomatic carotid disease in patients undergoing cardiovascular surgery. Surgery90:1075-1083, 1981.
19.
Barnes RW: Asymptomatic carotid disease in patients undergoing major cardiovascular operations: Can prophylactic endarterectomy be justified? Ann Thorac Surg42:S36-S40-, 1986.
20.
Piotrowski JJ, Bernard VM, Rubin JR, et al: Timing of carotid endarterectomy after acute stroke. J Vasc Surg11:45-52, 1990.
Ouriel K., Ricotta JJ, Green RM, et al: Carotid endarterectomy for nonhemispheric cerebral symptoms: Patient selection with ocular pneumoplethysmography. J Vasc Surg4:115-118, 1986.
23.
Goldstone J.: Evolving stroke secondary to carotid artery atherosclerosis. In: Current Therapy in Vascular Surgery, ed. by Ernst CB, Stanley JC.Philadelphia: Decker, 1987, pp 7-9.
24.
Brook RH, Park RE, Chassin MR, et al: Predicting the appropriate use of carotid endarterectomy, upper gastrointestinal endoscopy, and coronary angiography. N Eng J Med323:1173-1177, 1990.
