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(Stroke. 1999;30:12-15.)
© 1999 American Heart Association, Inc.

Original Contributions

Improving the Appropriateness of Carotid Endarterectomy

Results of a Prospective City-Wide Study

John H. Wong, MD, MSc; Tracey B. Lubkey, RN; Maria E. Suarez-Almazor, MD, PhD J. Max Findlay, MD, PhD

From the Division of Neurosurgery, Department of Surgery (J.H.W., J.M.F.), Department of Clinical Quality Improvement (T.B.L.), and Department of Public Health Sciences (M.E.S-A.), MacKenzie Health Sciences Centre, University of Alberta, Edmonton, Alberta, Canada.

Correspondence to J.M. Findlay, Division of Neurosurgery, Department of Surgery, 2D1.02 MacKenzie Health Sciences Centre, University of Alberta, 8440-112 St, Edmonton, AB, Canada T6G 2B7. E-mail jmfind{at}planet.eon.net

Background and Purpose—In light of previously reported concerns regarding carotid endarterectomy (CEA) use in our city, our goal was to determine the influence of a prospective audit and educational campaign on the performance of CEA with respect to surgical appropriateness and complication frequency.

Methods—Results of our previous audit of 291 CEAs, along with CEA practice guidelines and notification of prospective surveillance, were supplied to surgeons performing CEA in our city. After this, 184 consecutive patients undergoing CEA from September 1996 to August 1997 were followed prospectively. On the basis of blinded standardized remeasurements of angiographic carotid stenoses, CEA was classified as appropriate for patients with symptomatic carotid stenoses 70%, uncertain for those with symptomatic stenoses <70% or asymptomatic stenoses 60%, and inappropriate for patients with asymptomatic carotid stenoses <60% or preoperative neurological or medical instability.

Results—Forty percent of patients were asymptomatic. Compared with our prior audit, the rate of appropriate CEAs improved from 33% previously to 49% of cases in the present study (P=0.0005), uncertain indications did not change significantly (49% versus 47%; P=0.61), and inappropriate indications dropped from 18% to 4% (P=0.00002). Perioperative stroke or death occurred in 6.4% of symptomatic patients but developed in only 2.7% of asymptomatic patients, which was improved from the 5.1% rate previously found.

Conclusions—In our city, the use of a surgical audit identified areas of concern regarding CEA, and subsequent education and ongoing surveillance significantly improved the use and performance of this procedure.

Key Words: carotid endarterectomy • carotid stenosis • health services misuse

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