Endarterectomy for asymptomatic carotid artery stenosis

BMJ 1995; 311 doi: https://doi.org/10.1136/bmj.311.7013.1113 (Published 28 October 1995) Cite this as: BMJ 1995;311:1113
  1. Craig D Irvine,
  2. Roger N Baird,
  3. Peter M Lamont,
  4. Alun H Davies
  1. Craig D Irvine is supported by the Stroke Association.
  2. Research fellow in surgery Consultant surgeon Consultant surgeon Department of Surgery, Royal Infirmary, Bristol BS2 8HW
  3. Senior lecturer Department of Surgery, Charing Cross Hospital, London W6 8RF

    Reasonable doubt justifies randomisation

    European and North American clinicians have always differed in their management of carotid artery disease.1 Carotid endarterectomy is one of the commonest vascular procedures in North America, with over 360 operations per million population being performed each year.1 Meanwhile, despite the fact that the first carotid reconstruction was performed in Britain,1 selection for the procedure in Europe has been sporadic. British data for 1993-4 confirm that fewer than 40 carotid endarterectomies are performed per million population per year (personal communications from Department of Health, England; NHS Information and Statistics Division, Scotland; and Department of Health and Social Services, Northern Ireland, 1995).

    Two major multicentre trials, the North American symptomatic carotid endarterectomy trial and the European carotid surgery trial, both published in 1991, have helped to define the role of carotid endarterectomy in patients with symptoms, such as transient ischaemic attacks and non-disabling strokes.2 3 In symptomatic patients with an internal carotid artery stenosis of greater than 70%, endarterectomy produced a 75% reduction in rates of stroke over two to three years when compared with best medical treatment. These trials meant that carotid endarterectomy became a member of that small group of preventive surgical procedures that have withstood the test of a randomised controlled trial.

    Neurologists' lack of confidence in the outcome of carotid endarterectomy has contributed to low rates of referral in Europe.1 The benefit to patients with symptoms is acknowledged, but the impact of the operation on preventing stroke in the population has been challenged, as highlighted recently in the BMJ.4 Health service statistics suggest that the provision of endarterectomy for symptomatic patients is not uniform across the country. Given that Britain cannot optimally provide for patients …

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