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Two millennia ago Julius Caesar opined that “men willingly believe what they wish.” There is some evidence that this observation still applies to many in the medical community when dealing with carotid artery disease.
In 1991, the North American Symptomatic Carotid Endarterectomy Trial (NASCET) and the European Carotid Surgery Trial (ECST) proved that endarterectomy was beneficial for patients symptomatic with 70 to 99% stenosis. With only 1,000 patients, the trials established what the previous anecdotal experiences of one million patients had failed to affirm. The absolute risk reduction of ipsilateral stroke from endarterectomy in NASCET was 17.5%.1 In 1998 an aggregation of 6,000 patients with < 70% and > 50% stenosis were reported by both trials to have a reduced benefit.2,3 ⇓ Careful selection of candidates is mandatory. They must be similar to the studies’ patients.
The Asymptomatic Carotid Atherosclerosis Study (ACAS), reported a significant benefit for endarterectomy in asymptomatic individuals.4 The risk/benefit ratio was narrow and the number of asymptomatic subjects needed to treat (NNT) to prevent one stroke in 2 years is between 67 and 83.5
These randomized trials have clarified the criteria for achieving benefit from endarterectomy. Caution must be exerted in applying this new knowledge, as applied in the three areas of importance: choice of surgeon, choice of patient, and choice of preliminary investigations.
Two articles in this issue, one by O’Neill et al.6 and the other by Chaturvedi et al.,7 report on the first of these concerns: dealing with …
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