Results of carotid endarterectomy with prospective neurologist follow-up

To the Editor:

Chaturvedi et al.1 report on neurologist follow-up in 44 patients with carotid endarterectomy (CE) over a 4-year period. Of these, 70.5% were referred for symptomatic stenosis and 29.5% were asymptomatic. Their 30-day mortality rate was 4.5% and 30-day stroke and death rate was 11.4%. We find these complication rates alarmingly high. The authors conclude, based on limited data, that “unless neurologists are consistently involved in the preoperative and postoperative evaluation of patients who undergo CE, the complication rate of this procedure is likely to be underestimated.” We found no difference in complication rates reported by either vascular surgeons or neurologists at our center. Our vascular surgeons performed 650 CE last year with combined stroke/mortality risk of 2.2% in symptomatic and 1.9% in asymptomatic patients.2 In 1990, when only 66 CE were done, the combined stroke/mortality rate was 4.75%,2 still below that reported by the authors. Perioperative complications reported by Chaturvedi et al.1 were in high-risk patients biased toward worse outcome. Combination coronary bypass grafting with CE has perioperative stroke rates of 2 to 20%.3 Occluded contralateral carotid artery increases ipsilateral stroke risk twofold with CE.4

The benefit of CE in patients with symptomatic or asymptomatic carotid stenosis is based on performing surgeons having combined morbidity and mortality rates of <6% and <3%.1,5⇓ Complications exceeding these amounts eliminates the benefit of surgery. Successful CE is also dependent on surgical skills and high-volume surgeons and hospitals seem to have better results.6 Studies cited by Chaturvedi et al.1 reporting similar high CE complication rates were from older, nonrandomized pre–North American Symptomatic Carotid Endarterectomy Trial (NASCET) trials, without benefit of current criteria for patient selection.7,8⇓ The high complication rates reported by the authors are likely due to referral base …