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May 10, 1995, Vol 273, No. 18 >
ARTICLE | May 10, 1995

Endarterectomy for Asymptomatic Carotid Artery Stenosis: Title and subTitle BreakResolving the Controversy FREE

Marc R. Mayberg, MD; H. Richard Winn, MD
[+] Author Affiliations

Reprint requests to Department of Neurological Surgery, University of Washington, Mail Stop RI-20, Seattle, WA 98195 (Dr Mayberg).


JAMA. 1995;273(18):1459-1461. doi:10.1001/jama.1995.03520420075042
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References

Since its inception in the 1950s, carotid endarterectomy has been widely applied as a means to prevent cerebral infarction. The removal of stenotic or ulcerated lesions at the cervical carotid bifurcation appeared to be a logical and practical approach to stroke prevention. However, the appropriateness of this operation became a matter of controversy in the mid 1980s,1,2 in part because of the lack of objective data demonstrating the efficacy of carotid endarterectomy in preventing stroke. Subsequent to that time, six prospective, randomized trials for endarterectomy have been reported,3-8 five of which have shown benefit for surgery in preventing cerebral ischemia.

Three trials4-6 randomized patients with symptomatic carotid stenosis (ie, transient ischemic attack, amaurosis fugax, or small completed stroke ipsilateral to the carotid narrowing). Several notable features were common to all three trials of symptomatic carotid stenosis. First, carotid endarterectomy provided significant protection against subsequent ipsilateral stroke in

REFERENCES

1 +
Barnett HJM, Plum F, Walton JN.  Carotid endarterectomy—an expression of concern. Stroke . 1984;;15:941-943.
2 +
Warlow C.  Carotid endarterectomy: does it work? Stroke . 1984;;15:1068-1076.
3 +
CASANOVA Study Group.  Carotid surgery versus medical therapy in asymptomatic carotid stenosis. Stroke . 1991;;22:1229-1235.
4 +
European Carotid Surgery Trialists' Collaborative Group.  European Carotid Surgery Trial: interim results for symptomatic patients with severe (70-99%) or with mild (0-29%) carotid stenosis. Lancet . 1991;;337:1235-1243.
5 +
North American Symptomatic Carotid Endarterectomy Trial Collaborators.  Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade stenosis. N Engl J Med . 1991;;325:445-453.
6 +
Mayberg MR, Wilson SE, Yatsu F, et al, for the Veterans Affairs Cooperative Studies Program 309.  Carotid endarterectomy and prevention of cerebral ischemia in asymptomatic carotid stenosis. JAMA . 1991;;266:3289-3294.
7 +
Hobson RWII, Weiss DG, Fields WS, et al, for the Veterans Affairs Cooperative Study Group.  Efficacy of carotid endarterectomy for asymptomatic carotid stenosis. N Engl J Med . 1993;;328:221-227.
8 +
Executive Committee for the Asymptomatic Carotid Atherosclerosis Study.  Endarterectomy for asymptomatic carotid artery stenosis. JAMA . 1995;;273:1421-1428.
9 +
The Canadian Cooperative Study Group.  A randomized trail of aspirin and sulfinpyrazone in threatened stroke. N Engl J Med . 1978;;299:53-59.
10 +
Candelise L, Landi G, Perrone P, et al.  A randomized trial of aspirin and sulfinpyrazone in patients with TIA. Stroke . 1982;;13:175-179.
11 +
Moore WS, Barnet HJM, Beebe HG, et al.  Guidelines for carotid endarterectomy: a multidisciplinary consensus statement from the Ad Hoc Committee, American Heart Association. Stroke . 1995;;26:188-201.
12 +
Feinberg WR, Albers GW, Barnett HJM, et al.  Guidelines for the management of transient ischemic attacks. Circulation . 1994;;89:2950-2965.
13 +
Matchar DB, Duncan PW, Sansa GP, et al.  The Stroke Prevention Patient Outcomes Research Team: goals and methods. Stroke . 1993;;21:2135-2142.
14 +
Matchar D. Carotid endarterectomy: decision-making and cost analysis. Presented at Congress of Neurological Surgeons Annual Meeting; October 3,1994; Chicago, Ill.
15 +
Haynes RB, Taylor DW, Sackett DL, Fox A, Rankin R, Barnett H.  Poor performance of Doppler in detecting high-grade carotid stenosis. Clin Res . 1992;;40:184A.
16 +
Srinivasan J, Weiss D, Mayberg MR.  Duplex accuracy compared to angiography in the V.A. trial for carotid endarterectomy. Neurosurgery . 1995;;36:648-655.
17 +
Chikos P, Fisher L, Hirsch J, Harley J, Thiele B, Strandness DJ.  Observer variability in evaluating extracranial carotid artery stenosis. Stroke . 1983;;14:885-892.
18 +
Howard VJ, Toole JF, Grizzle J, et al.  Comparison of multicenter study designs for investigation of the efficacy of carotid endarterectomy. Stroke . 1992;;23:583-593.
19 +
Anson J, Heiserman JE, Drayer BP, Spetzler RF.  Surgical decisions on the basis of magnetic resonance angiography of the carotid arteries. Neurosurgery . 1993;; 32:335-343.
20 +
Goldstein LB, McCrory DC, Landsman PB, et al.  Multicenter review of preoperative risk factors for carotid endarterectomy in patients with ipsilateral symptoms. Stroke . 1994;;25:2096-2097.

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1 +
Barnett HJM, Plum F, Walton JN.  Carotid endarterectomy—an expression of concern. Stroke . 1984;;15:941-943.
2 +
Warlow C.  Carotid endarterectomy: does it work? Stroke . 1984;;15:1068-1076.
3 +
CASANOVA Study Group.  Carotid surgery versus medical therapy in asymptomatic carotid stenosis. Stroke . 1991;;22:1229-1235.
4 +
European Carotid Surgery Trialists' Collaborative Group.  European Carotid Surgery Trial: interim results for symptomatic patients with severe (70-99%) or with mild (0-29%) carotid stenosis. Lancet . 1991;;337:1235-1243.
5 +
North American Symptomatic Carotid Endarterectomy Trial Collaborators.  Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade stenosis. N Engl J Med . 1991;;325:445-453.
6 +
Mayberg MR, Wilson SE, Yatsu F, et al, for the Veterans Affairs Cooperative Studies Program 309.  Carotid endarterectomy and prevention of cerebral ischemia in asymptomatic carotid stenosis. JAMA . 1991;;266:3289-3294.
7 +
Hobson RWII, Weiss DG, Fields WS, et al, for the Veterans Affairs Cooperative Study Group.  Efficacy of carotid endarterectomy for asymptomatic carotid stenosis. N Engl J Med . 1993;;328:221-227.
8 +
Executive Committee for the Asymptomatic Carotid Atherosclerosis Study.  Endarterectomy for asymptomatic carotid artery stenosis. JAMA . 1995;;273:1421-1428.
9 +
The Canadian Cooperative Study Group.  A randomized trail of aspirin and sulfinpyrazone in threatened stroke. N Engl J Med . 1978;;299:53-59.
10 +
Candelise L, Landi G, Perrone P, et al.  A randomized trial of aspirin and sulfinpyrazone in patients with TIA. Stroke . 1982;;13:175-179.
11 +
Moore WS, Barnet HJM, Beebe HG, et al.  Guidelines for carotid endarterectomy: a multidisciplinary consensus statement from the Ad Hoc Committee, American Heart Association. Stroke . 1995;;26:188-201.
12 +
Feinberg WR, Albers GW, Barnett HJM, et al.  Guidelines for the management of transient ischemic attacks. Circulation . 1994;;89:2950-2965.
13 +
Matchar DB, Duncan PW, Sansa GP, et al.  The Stroke Prevention Patient Outcomes Research Team: goals and methods. Stroke . 1993;;21:2135-2142.
14 +
Matchar D. Carotid endarterectomy: decision-making and cost analysis. Presented at Congress of Neurological Surgeons Annual Meeting; October 3,1994; Chicago, Ill.
15 +
Haynes RB, Taylor DW, Sackett DL, Fox A, Rankin R, Barnett H.  Poor performance of Doppler in detecting high-grade carotid stenosis. Clin Res . 1992;;40:184A.
16 +
Srinivasan J, Weiss D, Mayberg MR.  Duplex accuracy compared to angiography in the V.A. trial for carotid endarterectomy. Neurosurgery . 1995;;36:648-655.
17 +
Chikos P, Fisher L, Hirsch J, Harley J, Thiele B, Strandness DJ.  Observer variability in evaluating extracranial carotid artery stenosis. Stroke . 1983;;14:885-892.
18 +
Howard VJ, Toole JF, Grizzle J, et al.  Comparison of multicenter study designs for investigation of the efficacy of carotid endarterectomy. Stroke . 1992;;23:583-593.
19 +
Anson J, Heiserman JE, Drayer BP, Spetzler RF.  Surgical decisions on the basis of magnetic resonance angiography of the carotid arteries. Neurosurgery . 1993;; 32:335-343.
20 +
Goldstein LB, McCrory DC, Landsman PB, et al.  Multicenter review of preoperative risk factors for carotid endarterectomy in patients with ipsilateral symptoms. Stroke . 1994;;25:2096-2097.

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