Published online before print May 8, 2003, doi: 10.1161/01.STR.0000072514.79745.7D
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(Stroke. 2003;34:1464.)
© 2003 American Heart Association, Inc.
Original Contributions |
Revisiting the Appropriateness of Carotid Endarterectomy
From the Departments of Health Policy and Medicine (E.A.H., M.R.C.), Neurology (S.T.), and Surgery (L.H.H.), Mount Sinai School of Medicine, New York, NY; Department of Surgery, Albany Medical College, Albany, NY (A.J.P.); Department of Surgery, Maimonides Medical Center, Brooklyn, NY (E.A.); Department of Surgery, Englewood Hospital, Englewood, NJ (H.D.); Department of Surgery, Long Island Jewish Hospital, New Hyde Park, NY (G.F.); and Department of Surgery, New York University School of Medicine, New York, NY.
Correspondence to Ethan A. Halm, MD, MPH, Department of Health Policy, Box 1077, Mount Sinai School of Medicine, One Gustave L. Levy Place, New York, NY 10029. E-mail ethan.halm{at}mountsinai.org
Background and Purpose— In the 1980s, carotid endarterectomy was controversial because proof of efficacy was lacking, complication rates were high, and one third of cases were reported to be inappropriate. Since publication of several randomized controlled trials (RCTs), rates of carotid endarterectomy have doubled nationwide. This study assesses the appropriateness and use of carotid endarterectomy since publication of the RCTs.
Methods— Using the literature, we developed a list of 1557 mutually exclusive indications for carotid endarterectomy and asked a panel of national experts to rate the appropriateness of each indication using the RAND methodology. We used these ratings to assess appropriateness in a sample of 2124 patients who underwent the procedure in 1997 to 1998 in 6 hospitals. We also analyzed the reasons for the procedure and rates of death, stroke, and myocardial infarction within 30 days of surgery.
Results— Overall, 84.9% of operations were done for appropriate reasons, 4.5% for uncertain reasons, and 10.6% for inappropriate reasons. Among procedures considered inappropriate, the most common reasons were high comorbidity (46.6%) and minimal stenosis (27.1%). Overall, 72.5% were asymptomatic, 17.4% had a carotid transient ischemic attack, and 10.1% had a stroke. The 30-day rate of death or stroke was 5.47% for symptomatic patients and 2.26% for asymptomatic patients. Among patients having combined carotid and coronary artery bypass graft surgery, the rate was 10.32%. The complication rate in asymptomatic patients with high comorbidity was 5.56%.
Conclusions— Since the RCTs, rates of overuse appear to have fallen considerably, although they are still significant. A major shift has occurred toward operating on asymptomatic patients. Although overall complication rates were low, rates among asymptomatic patients with high comorbidity exceeded recommended thresholds.
Key Words: carotid endarterectomy • complications • health services misuse • outcome
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