[Should certain carotid artery stenoses be surgically treated?]

Abstract

Carotid endarterectomy is controverted. We present the available data and endeavour to answer the following questions: 1) what is the probability of morbidity and mortality from ipsilateral cerebral infarction due to asymptomatic or symptomatic extracranial carotid stenosis (transient or prolonged regressive ischaemic strokes) medically treated or untreated? 2) what is the peri-operative morbidity-mortality rate? 3) does the degree of stenosis affect the clinical course? 4) does the presence of ulcerations play a role? 5) what is the long-term probability of ipsilateral cerebral infarction when the stenosis has been operated with success? 6) should endarterectomy be regarded as an effective treatment? and if so, in which cases? Our study of asymptomatic stenoses has shown that the mean peri-operative morbidity-mortality rate was 4.22 percent and the long-term incidence of ipsilateral infarction was 0.34 percent/year for operated stenoses and 0.50 percent/year for all nonoperated stenoses; the latter figure rose to 1.18 percent/year in cases with severe stenosis and to more than 10 percent/year in cases with extensive and irregular ulcerations. In symptomatic stenoses, the cumulative peri-operative morbidity-mortality rate was 5.5 percent. The long-term annual incidence of ipsilateral cerebral infarction was 0.67 percent in patients operated upon and 2.70 percent in patients unoperated upon. A comparison of the natural history of asymptomatic carotid stenoses and of stenoses which were responsible for transient or prolonged regressive ischaemic strokes with the results of surgery showed that endarterectomy is: 1) probably justified in cases with deep and irregular ulcerations with or without symptoms and stenotic or nonstenotic; 2) perhaps justified in cases with symptomatic stenosis without ulcerations. These conclusions should be moderated as they rest on general data and do not take into account a number of factors that are often neglected in the literature, notably the quality of the results obtained by each individual surgeon.