In new years, the rate of carotid e...

In new years, the rate of carotid endarterectomy has more than doubled in the United States, with more than 150000 performances performed in 1998. However, [i]connoisseur[/i]s disagree on the best arrangement to select patients for this proceeding European guidelines are based onward studies that show benefit barely in men with more than 80 percent stenosis and women with stenosis of more than 90 percent However, North American guidelines commit that surgery be considered in symptomatic patients with stenosis of 50 percent or more. To subdue differences in measurements between various clinical trials, Rothwell and colleagues re-examined data from the three largest studies to determine the effectiveness of endarterectomy at different of the same heights of stenosis.

Because sum of two units of the five randomized controll trials of endarterectomy are not compatible with generally received surgical practice, the researchers obtained data from the remaining three studies, the European Carotid Surgery Trial, the North American Symptomatic Carotid Endarterectomy Trial, and the Veterans Affairs trial. These three trials recruited patients with symptoms attributable to demonstrated stenosis of the carotid artery and randomly allocated patients to best medical treatment or immediate carotid endarterectomy and best medical treatment. Data were available for more than 6000 patients who were followed for 35000 patient-years. The researchers reassessed original data for each patient to standardize definitions of stenosis and techniques of measurement and to establish for the use of all outcome measures for the three trials. After reassessment of each case, data were reanalyzed to assess death during surgery or within 30 days after surgery time to first hardship and any stroke within 30 days of surgery

Overall, surgery increased the risk of pat within five years for patients with les than 30 percent stenosis (see the accompanying table). In patients with stenosis between 30 and 49 percent surgery had no purport Surgery had marginal benefit when stenosis was 50 to 69 percent and was highly beneficial in patients with at least 70 percent stenosis without near occlusion.

The authors stres that carotid endarterectomy can have significant morbidity and is associated with any mortality, and that the morbidity from minor vascular changes in the brain may not be recognized or documented. Patients face a 7 percent risk of death or knock within 30 days of the deed The decision about treatment of symptomatic carotid stenosis must be individualized, unless these findings indicate that surgery is beneficial barely when the stenosis is at least 50 percent The greatest benefit is reached in stenoses of more than 70 percent

ANNE D WALLING, MD

Rothwell PM et al. Analysis of plashed data from the randomised controll trials of endarterectomy for symptomatic carotid stenosis. Lancet January 11 2003;361:107-16

EDITOR'S NOTE: individual of the most challenging tasks for family physicians is to dissuade patients or families from inappropriately aggressive therapy. This research indicates that even in patients who have experienced significant symptoms, medical therapy is more appropriate than surgical treatment unles there is at least 70 percent stenosis. The investigation does not help with asymptomatic patients whose stenosis is discovered incidentally or by way of screening. Even in symptomatic patients, subgroup analysis would be highly useful to help us advise patients who are repeatedly anxious to "do everything possible to avert a stroke" For many patients, the surgery strike one as beings to make sense, and they do not welcome cautions or the advice that medical therapy can be more effective. calm after a bad outcome, I have had families say they were "glad everything possible was done." wherefore is conservative treatment always assumed to be inferior? What happened to "First, do no harm"?--A.D.W.

COPYRIGHT 2003 American Academy of Family Physicians

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