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(Stroke. 1998;29:1475-1476.)
© 1998 American Heart Association, Inc.

Letters to the Editor

Concerns Regarding Carotid Endarterectomy Guidelines

Seemant Chaturvedi, MD

Department of Neurology, Wayne State University, Detroit, Michigan

Alison Halliday, MD

Department of Surgery, St. Mary's Hospital, London, UK

To the Editor:

We were surprised to read the rather unequivocal endorsement¹ by the American Heart Association writing group of carotid endarterectomy (CE) for asymptomatic stenosis of greater than 60%. This position does not represent the viewpoint of all stroke neurologists or surgeons, and some professional groups have recently come to the exact opposite conclusion, not recommending CE for asymptomatic stenosis.²

The writing group states that CE is beneficial if the surgical complication rate is less than 3%. Current evidence indicates that CE complication rates are not being closely monitored at US hospitals.³ A recent study found that the surgical complication rates were either unknown or not being monitored at over 50% of teaching hospitals in the United States.⁴ In the "real world" of CE practice, it is unlikely that a complication rate this low can be uniformly achieved, and a 1991 analysis of Medicare data found that the death rate associated with CE was 2.3%.⁵

In addition, we and others have concerns that the Asymptomatic Carotid Atherosclerosis Study (ACAS) results cannot be generalized.^{6 7 8 9} Only 4% of the eligible patients were entered into the study.¹⁰ In addition, 29% of the surgeons who applied for participation in the trial were either rejected or did not complete the credentialing process.¹¹ Thus, in the ideal setting for producing a positive surgical result (namely, combining low-surgical-risk patients with surgeons vetted for their excellence), a statistically significant result was obtained, which may not be clinically meaningful to all clinicians.

Finally, for full disclosure, it would . . . [Full Text of this Article]

José Biller, MD

Department of Neurology, Indiana University School of Medicine

John E. Castaldo, MD

Division of Neurology, Penn State at Hershey

Anthony D. Whittemore, MD

Department of Surgery, Harvard Medical School

Robert E. Harbaugh, MD

Section of Neurosurgery, Dartmouth-Hitchcock Medical Center

Robert J. Dempsey, MD

Department of Neurosurgery, University of Wisconsin Medical Center

Louis R. Caplan, MD

Department of Neurology, New England Medical Center

Timothy F. Kresowik, MD

Department of Surgery, University of Iowa Hospitals and Clinics

David B. Matchar, MD

Center for Clinical Health Policy, Duke University

James F. Toole, MD

Department of Neurology, Bowman Gray School of Medicine

J. Donald Easton, MD

Department of Neurology, Brown University

Harold P. Adams, Jr, MD

Department of Neurology, University of Iowa Hospitals

Lawrence M. Brass, MD

Department of Neurology, Yale University School of Medicine

Robert W. Hobson, II, MD

Department of Surgery, University of Medicine and Dentistry of New Jersey, New Jersey Medical School

Thomas G. Brott, MD

Department of Neurology, University of Cincinnati College of Medicine

Linda Sternau, MD

Department of Neurosurgery, Mt Sinai Medical Center, Miami Beach, Florida