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The Appropriateness of Carotid Endarterectomy-Reply

Nancy J. Merrick, MD; Robert H. Brook, MD; Arlene Fink, PhD; David H. Solomon, MD
JAMA. 1987;257(16):2167. doi:10.1001/jama.1987.03390160052021.
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In Reply.—  We would like to thank Drs Smith and Stiers for providing information about the number of and mortality from carotid endarterectomies in VA hospitals. Although the number of procedures has leveled off, the number performed in 1984 is still substantially higher than that for 1981, the year of our study. Although a mortality rate of 2.28% compares favorably with national rates, it may not be low enough to justify surgery for many patients, particularly those who are asymptomatic. Besides mortality, complications of carotid endarterectomy include stroke and myocardial infarction, and their rates generally exceed mortality rates.1,2 Our expert panel suggested that appropriateness of carotid endarterectomy's use would drop substantially if a surgeon's known complication rate was 5% to 8% and would be totally inappropriate if that rate exceeded 8%. Had we adjusted appropriateness scores for the 5.6% complication rate in this study, then 77% of the procedures


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