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Page: Indications
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Surgical intervention to relieve atherosclerotic obstruction of the carotid arteries was first performed at St. Mary’s Hospital, London, in 1954. Since then, evidence for it’s effectiveness in different patient groups has accumulated. In 2003 nearly 140,000 carotid endarterectomies were performed in the USA (Halm).
The aim of CEA is to prevent the adverse sequelae of carotid artery stenosis secondary to atherosclerotic disease, i.e. stroke. As with any prophylactic operation, careful evaluation of the relative benefits and risks of the procedure is required on an individual patient basis. Peri-operative combined mortality and major stroke risk is 2 – 5%.
Carotid stenosis is diagnosed with ultrasound doppler studies of the neck arteries or magnetic resonance arteriography (MRA). The circle of Willis typically provides a collateral blood supply. Symptoms have to affect the other side of the body; if they do not, they may not be caused by the stenosis, and arterectomy it will be of minimal benefit.
The North American Symptomatic Carotid Endarterectomy Trial (NASCET) and the European Carotid Surgery Trial (ECST) are both large randomized class 1 studies which have helped define current indications for carotid endarterectomy. The NASCET found that for every six patients treated, one major stroke would be prevented at two years (i.e. a “number needed to treat” (NNT) of six) for symptomatic patients with a 70 – 99% stenosis. Symptomatic patients with less severe carotid occlusion (50 – 69%) had a smaller benefit, with a NNT of 22 at five years (Barclay). In addition, co-morbidity adversely affects the outcome; patients with multiple medical problems have a higher post-operative mortality and hence benefit less from the procedure. The European asymptomatic carotid surgery trial (ACST) found that asymptomatic patients may also benefit from the procedure, but only the group with a high grade stenosis (greater than 75%). For maximum benefit patients should be operated on soon after a TIA or stroke, preferably within the first month.
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Important notice:
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