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August 14, 1987, Vol 258, No. 6 >
ARTICLE | August 14, 1987

Endarterectomy in Carotid Artery Disease: Title and subTitle BreakA Decision Analysis FREE

David B. Matchar, MD; Stephen G. Pauker, MD
[+] Author Affiliations

Read in part before the annual meeting of the Society for Medical Decision Making, Asilomar, Calif, Oct 20, 1985.

Reprint requests to Health Services Research Field Program (152), Durham Veterans Administration Medical Center, 508 Fulton St, Durham, NC 27705 (Dr Matchar).


JAMA. 1987;258(6):793-798. doi:10.1001/jama.1987.03400060069032
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References

Carotid endarterectomy is being performed with increasing frequency, now over 100000 times annually in the United States. We used the methods of decision analysis to examine the question of when to perform carotid endarterectomy. We developed a model that simulates the possible outcomes for a cohort of patients at risk for stroke. Estimates of surgical risk, surgical efficacy, annual stroke rate, and nonstroke mortality were derived from the literature. Using sensitivity analysis, we found that surgical risk, surgical efficacy, and stroke risk are the most important factors in determining when surgery is appropriate. By examining a series of clinical scenarios, we constructed guidelines for carotid endarterectomy based on the estimated risk of future stroke. The analysis suggests that for patients with a risk of less than 3% per year, surgery is not indicated. For patients with risk between 3% and 5% per year, low-risk surgery can be expected to provide a benefit of at most three months of quality life, depending on the efficacy of surgery. For stroke risk between 5% and 10% per year, even high-risk surgery is favored if surgical efficacy is above 30% Above a stroke risk of 10% per year, even high-risk, low-efficacy surgery should be considered. The challenge to advocates of carotid endarterectomy is to develop a cost-effective strategy for identifying patients at high risk for stroke.

(JAMA 1987;258:793-798)

REFERENCES

1 +
Byer JA, Easton JD:  Therapy of ischemic cerebrovascular disease . Ann Intern Med 1980;;93: 742-756.
2 +
Bauer RB, Meyer JS, Fields WS, et al:  Joint study of extracranial arterial occlusion: III. Progress report of controlled study of long-term survival in patients with and without operation . JAMA 1969;;208:509-518.
3 +
Fields WS, Maslenikov V, Meyer JS, et al:  Joint study of extracranial arterial occlusion: V. Progress report of prognosis following surgery or nonsurgical treatment for transient cerebral ischemic attacks and cervical carotid artery lesions . JAMA 1970;;211:1993-2003.
4 +
Dyken ML, Pokras R:  The performance of endarterectomy for disease of the extracranial arteries of the head . Stroke 1984;;15:948-950.
5 +
Dyken ML:  Carotid endarterectomy studies: A glimmering of science . Stroke 1986;;17:355-358.
6 +
Brott TG, Labutta RJ, Kempczinski RF:  Changing patterns in the practice of carotid endarterectomy in a large metropolitan area . JAMA 1986;; 255:2609-2612.
7 +
Hass WK, Jonas S:  Caution falling rock zone: An analysis of the medical and surgical management of threatened stroke . Proc Inst Med Chgo 1980;;33: 80-84.
8 +
Chambers BR, Norris JW:  The case against surgery for asymptomatic carotid stenosis . Stroke 1984;;15:964-967.
9 +
McNeil BJ, Weichselbaum R, Pauker SG:  Speech and survival: Tradeoffs between quality and quantity of life in laryngeal cancer . N Engl J Med 1981;;305:982-987.
10 +
Pauker SG:  Coronary artery surgery: The use of decision analysis . Ann Intern Med 1976;;85:8-18.
11 +
Pauker SG, Kassirer JP:  Decision analysis . N Engl J Med 1987;;316:250-258.
12 +
Kassirer JP, Moskowitz AJ, Lau J, et al:  Decision analysis: A progress report . Ann Intern Med 1987;;106:275-291.
13 +
Weinstein ML, Fineberg HV: Clinical Decision Analysis . Philadelphia, WB Saunders Co, 1980;.
14 +
Beck RJ, Pauker SG:  The Markov process in medical prognosis . Med Decis Making 1983;;3: 419-458.
15 +
Weinberger J:  Clinical applications of noninvasive carotid artery testing . J Am Coll Cardiol 1985;;5:137-148.
16 +
Eisenberg RL, Bank WO, Hedgcock MW:  Neurologic complications of angiography for cerebrovascular disease . Neurology 1980;;30:895-897.
17 +
Sundt TM Jr, Sandok BA, Whisnant JP:  Carotid endarterectomy: Complications and preoperative assessment of risk . Mayo Clin Proc 1975;; 50:301-306.
18 +
Rubio PA, Guinn GA:  Myocardial infarction following carotid endarterectomy . Cardiovasc Dis Bull Tex Heart Inst 1975;;2:402-404.
19 +
De Bakey ME, Crawford ES, Cooley DA, et al:  Cerebral arterial insufficiency: One to 11-year results following arterial reconstructive operation . Ann Surg 1965;;161:921-945.
20 +
Ennix CL Jr, Lawrie GM, Morris GC Jr, et al:  Improved results of carotid endarterectomy in patients with symptomatic coronary disease: An analysis of 1546 consecutive carotid operations . Stroke 1979;;10:122-125.
21 +
DeWeese JA, Rob CG, Satran R, et al:  Results of carotid endarterectomies for transient ischemic attacks: Five years later . Ann Surg 1973;;178: 258-264.
22 +
Bouchard J-P, Fabia J, Simard D, et al:  Carotid endarterectomy: Survival rates of 227 patients . Can Med Assoc J 1975;;113:949-951.
23 +
Allen GS, Preziosi TJ:  Carotid endarterectomy: A prospective study of its efficacy and safety . Medicine 1981;;60:298-309.
24 +
Whisnant JP, Sandok BA, Sundt TM Jr:  Carotid endarterectomy for unilateral carotid system transient cerebral ischemia . Mayo Clin Proc 1983;;58:171-175.
25 +
Bernstein EF, Humber PB, Collins GM, et al:  Life expectancy and late stroke following carotid endarterectomy . Ann Surg 1983;;198:80-86.
26 +
Nunn DB:  Carotid endarterectomy: An analysis of 234 operative cases . Ann Surg 1975;;182: 733-738.
27 +
Toole JF, Yuson CP, Janeway R, et al:  Transient ischemic attacks: A prospective study of 225 patients . Neurology 1978;;28:746-753.
28 +
Fode NC, Sundt TM Jr, Robertson JT, et al:  Multicenter retrospective review of results and complications of carotid endarterectomy in 1981 . Stroke 1986;;17:370-376.
29 +
McNamara JO, Heyman A, Silver D, et al:  The value of carotid endarterectomy in treating transient cerebral ischemia of the posterior circulation . Neurology 1977;;27:682-684.
30 +
Heyman A, Wilkinson WE, Heyden S, et al:  Risk of stroke in asymptomatic persons with cervical arterial bruits: A population study in Evans County, Georgia . N Engl J Med 1980;;302:838-841.
31 +
Wolf PA, Kannel WB, Sorlie P, et al:  Asymptomatic carotid bruit and risk of stroke: The Framingham study . JAMA 1981;;245:1442-1445.
32 +
Cartlidge NEF, Whisnant JP, Elveback LR:  Carotid and vertebral-basilar transient cerebral ischemic attacks: A community study, Rochester, Minnesota . Mayo Clin Proc 1977;;52:117-120.
33 +
Muuronen A, Kaste M:  Outcome of 314 patients with transient ischemic attacks . Stroke 1982;;13: 24-31.
34 +
Canadian Cooperative Study Group:  A randomized trial of aspirin and sulfinpyrazone in threatened stroke . N Engl J Med 1978;;299:53-59.
35 +
American-Canadian Co-operative Study Group:  Persantine aspirin trial in cerebral ischemia: II. Endpoint results . Stroke 1985;;16: 406-415.
36 +
Heyden S, Heiss G, Heyman A, et al:  Cardiovascular mortality in transient ischemic attacks . Stroke 1980;;11:252-255.
37 +
Vital Statistics of the United States . National Center for Health Statistics, 1975;.
38 +
Beck JR, Pauker SG, Gottlieb JE, et al:  A convenient approximation of life expectancy (the 'DEALE'): II. Use in medical decision making . Am J Med 1982;;73:889-897.
39 +
Kurtzke JF:  Epidemiology of cerebrovascular disease , in Siekert RG (ed): Cerebrovascular Survey Report for Joint Council Subcommittee on Cerebrovascular Disease, National Institute of Neurological and Communicative Disorders and Stroke and National Heart and Lung Institute (Revised) . Rochester, Minn, Whiting Press, 1980;, pp 135-176.
40 +
Garraway WM, Akhtar AJ, Smith DL, et al:  The triage of stroke rehabilitation . J Epidemiol Community Health 1981;;35:39-44.
41 +
Sacco RL, Wolf PA, Kannel WB, et al:  Survival and recurrence following stroke: The Framingham study . Stroke 1982;;13:290-295.
42 +
Raiffa H: Decision Analysis: Introductory Lectures on Choices Under Uncertainty . Reading, Mass, Addison-Wesley Publishing Co, 1968;.
43 +
Whisnant JP, Matsumoto N, Elveback LR:  Transient cerebral ischemic attacks in a community: Rochester, Minnesota, 1955 through 1969 . Mayo Clin Proc 1973;;48:194-198.
44 +
Kassirer JP, Pauker SG:  The toss-up . N Engl J Med 1981;;305:1467-1469.
45 +
Chambers BR, Norris JW:  Outcome in patients with asymptomatic neck bruits . N Engl J Med 1986;;315:860-865.

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1 +
Byer JA, Easton JD:  Therapy of ischemic cerebrovascular disease . Ann Intern Med 1980;;93: 742-756.
2 +
Bauer RB, Meyer JS, Fields WS, et al:  Joint study of extracranial arterial occlusion: III. Progress report of controlled study of long-term survival in patients with and without operation . JAMA 1969;;208:509-518.
3 +
Fields WS, Maslenikov V, Meyer JS, et al:  Joint study of extracranial arterial occlusion: V. Progress report of prognosis following surgery or nonsurgical treatment for transient cerebral ischemic attacks and cervical carotid artery lesions . JAMA 1970;;211:1993-2003.
4 +
Dyken ML, Pokras R:  The performance of endarterectomy for disease of the extracranial arteries of the head . Stroke 1984;;15:948-950.
5 +
Dyken ML:  Carotid endarterectomy studies: A glimmering of science . Stroke 1986;;17:355-358.
6 +
Brott TG, Labutta RJ, Kempczinski RF:  Changing patterns in the practice of carotid endarterectomy in a large metropolitan area . JAMA 1986;; 255:2609-2612.
7 +
Hass WK, Jonas S:  Caution falling rock zone: An analysis of the medical and surgical management of threatened stroke . Proc Inst Med Chgo 1980;;33: 80-84.
8 +
Chambers BR, Norris JW:  The case against surgery for asymptomatic carotid stenosis . Stroke 1984;;15:964-967.
9 +
McNeil BJ, Weichselbaum R, Pauker SG:  Speech and survival: Tradeoffs between quality and quantity of life in laryngeal cancer . N Engl J Med 1981;;305:982-987.
10 +
Pauker SG:  Coronary artery surgery: The use of decision analysis . Ann Intern Med 1976;;85:8-18.
11 +
Pauker SG, Kassirer JP:  Decision analysis . N Engl J Med 1987;;316:250-258.
12 +
Kassirer JP, Moskowitz AJ, Lau J, et al:  Decision analysis: A progress report . Ann Intern Med 1987;;106:275-291.
13 +
Weinstein ML, Fineberg HV: Clinical Decision Analysis . Philadelphia, WB Saunders Co, 1980;.
14 +
Beck RJ, Pauker SG:  The Markov process in medical prognosis . Med Decis Making 1983;;3: 419-458.
15 +
Weinberger J:  Clinical applications of noninvasive carotid artery testing . J Am Coll Cardiol 1985;;5:137-148.
16 +
Eisenberg RL, Bank WO, Hedgcock MW:  Neurologic complications of angiography for cerebrovascular disease . Neurology 1980;;30:895-897.
17 +
Sundt TM Jr, Sandok BA, Whisnant JP:  Carotid endarterectomy: Complications and preoperative assessment of risk . Mayo Clin Proc 1975;; 50:301-306.
18 +
Rubio PA, Guinn GA:  Myocardial infarction following carotid endarterectomy . Cardiovasc Dis Bull Tex Heart Inst 1975;;2:402-404.
19 +
De Bakey ME, Crawford ES, Cooley DA, et al:  Cerebral arterial insufficiency: One to 11-year results following arterial reconstructive operation . Ann Surg 1965;;161:921-945.
20 +
Ennix CL Jr, Lawrie GM, Morris GC Jr, et al:  Improved results of carotid endarterectomy in patients with symptomatic coronary disease: An analysis of 1546 consecutive carotid operations . Stroke 1979;;10:122-125.
21 +
DeWeese JA, Rob CG, Satran R, et al:  Results of carotid endarterectomies for transient ischemic attacks: Five years later . Ann Surg 1973;;178: 258-264.
22 +
Bouchard J-P, Fabia J, Simard D, et al:  Carotid endarterectomy: Survival rates of 227 patients . Can Med Assoc J 1975;;113:949-951.
23 +
Allen GS, Preziosi TJ:  Carotid endarterectomy: A prospective study of its efficacy and safety . Medicine 1981;;60:298-309.
24 +
Whisnant JP, Sandok BA, Sundt TM Jr:  Carotid endarterectomy for unilateral carotid system transient cerebral ischemia . Mayo Clin Proc 1983;;58:171-175.
25 +
Bernstein EF, Humber PB, Collins GM, et al:  Life expectancy and late stroke following carotid endarterectomy . Ann Surg 1983;;198:80-86.
26 +
Nunn DB:  Carotid endarterectomy: An analysis of 234 operative cases . Ann Surg 1975;;182: 733-738.
27 +
Toole JF, Yuson CP, Janeway R, et al:  Transient ischemic attacks: A prospective study of 225 patients . Neurology 1978;;28:746-753.
28 +
Fode NC, Sundt TM Jr, Robertson JT, et al:  Multicenter retrospective review of results and complications of carotid endarterectomy in 1981 . Stroke 1986;;17:370-376.
29 +
McNamara JO, Heyman A, Silver D, et al:  The value of carotid endarterectomy in treating transient cerebral ischemia of the posterior circulation . Neurology 1977;;27:682-684.
30 +
Heyman A, Wilkinson WE, Heyden S, et al:  Risk of stroke in asymptomatic persons with cervical arterial bruits: A population study in Evans County, Georgia . N Engl J Med 1980;;302:838-841.
31 +
Wolf PA, Kannel WB, Sorlie P, et al:  Asymptomatic carotid bruit and risk of stroke: The Framingham study . JAMA 1981;;245:1442-1445.
32 +
Cartlidge NEF, Whisnant JP, Elveback LR:  Carotid and vertebral-basilar transient cerebral ischemic attacks: A community study, Rochester, Minnesota . Mayo Clin Proc 1977;;52:117-120.
33 +
Muuronen A, Kaste M:  Outcome of 314 patients with transient ischemic attacks . Stroke 1982;;13: 24-31.
34 +
Canadian Cooperative Study Group:  A randomized trial of aspirin and sulfinpyrazone in threatened stroke . N Engl J Med 1978;;299:53-59.
35 +
American-Canadian Co-operative Study Group:  Persantine aspirin trial in cerebral ischemia: II. Endpoint results . Stroke 1985;;16: 406-415.
36 +
Heyden S, Heiss G, Heyman A, et al:  Cardiovascular mortality in transient ischemic attacks . Stroke 1980;;11:252-255.
37 +
Vital Statistics of the United States . National Center for Health Statistics, 1975;.
38 +
Beck JR, Pauker SG, Gottlieb JE, et al:  A convenient approximation of life expectancy (the 'DEALE'): II. Use in medical decision making . Am J Med 1982;;73:889-897.
39 +
Kurtzke JF:  Epidemiology of cerebrovascular disease , in Siekert RG (ed): Cerebrovascular Survey Report for Joint Council Subcommittee on Cerebrovascular Disease, National Institute of Neurological and Communicative Disorders and Stroke and National Heart and Lung Institute (Revised) . Rochester, Minn, Whiting Press, 1980;, pp 135-176.
40 +
Garraway WM, Akhtar AJ, Smith DL, et al:  The triage of stroke rehabilitation . J Epidemiol Community Health 1981;;35:39-44.
41 +
Sacco RL, Wolf PA, Kannel WB, et al:  Survival and recurrence following stroke: The Framingham study . Stroke 1982;;13:290-295.
42 +
Raiffa H: Decision Analysis: Introductory Lectures on Choices Under Uncertainty . Reading, Mass, Addison-Wesley Publishing Co, 1968;.
43 +
Whisnant JP, Matsumoto N, Elveback LR:  Transient cerebral ischemic attacks in a community: Rochester, Minnesota, 1955 through 1969 . Mayo Clin Proc 1973;;48:194-198.
44 +
Kassirer JP, Pauker SG:  The toss-up . N Engl J Med 1981;;305:1467-1469.
45 +
Chambers BR, Norris JW:  Outcome in patients with asymptomatic neck bruits . N Engl J Med 1986;;315:860-865.

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