Abstract
In the last six years the indications for performance of carotid endarterectomy have become standardized by the availability of level one evidence from cooperative trial data. Four randomized cooperative trials for asymptomatic carotid disease and three randomized cooperative trials of symptomatic carotid disease have been completed and published. Asymptomatic carotid disease with 60% or greater linear stenosis on angiography has been shown to be better treated with surgery than with medical therapy alone. For symptomatic patients, linear stenoses of 70% or greater in all patients have been shown to have a significant benefit with surgical treatment. Symptomatic moderate stenosis of <50% is best treated medically, but NASCET now shows that surgery is best for >50% symptomatic stenosis in healthy patients. All surgical recommendations are based on a morbidity/mortality rate of 3% or less for the individual surgeon. Areas remain which were not addressed directly by randomized trials, and for which only lesser levels of evidence are available. These include Hollenhorst plaque, complete occlusion, silent cerebral infarcts, emergency surgery for stroke, and“stump”syndromes. This review discusses the evidence for carotid surgery in these categories, as well as my personal technique for successful carotid reconstruction.
