The Current Status of Carotid Endarterectomy Part I: Randomized Trials Versus Medical Management

A vascular surgeon is consulted to evaluate a patient because of carotid stenosis. By the time the surgeon enters the examining room or arrives at the bedside, he (she) is aware of the sex and age of the patient as well as the severity of the stenosis on a recent high-quality imaging study. After asking if the patient has had any related symptoms and how long ago they occurred, the surgeon has all of the information that is necessary to determine, in the absence of serious comorbidities, whether this patient is an appropriate candidate for carotid intervention and even how quickly it should be performed. Why? Because so much essential spadework comparing relative risks and benefits of carotid endarterectomy (CEA) versus medical treatment was done by the randomized clinical trials conducted in North America and Europe in the late 1980s and early 1990s. These trials may not be timeless, since contemporary antiplatelet agents and statin drugs could provide better stroke prevention than the management used in their medical cohorts. However, their conclusions still remain the benchmark for the selection of patients to have CEA or carotid angioplasty and stenting. Their subset analyses have been published during more than 25 years in a variety of journals, many of which are not ordinarily read by surgeons. This review is merely a reminder of their importance.