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Abstract Carotid endarterectomy is beneficial in selected patients with carotid atherosclerosis1-4; however, it has incontrovertible limitations. Carotid angioplasty is a potential alternative to surgical revascularization. Although angioplasty has not been submitted to a definitive clinical test, its potential advantages warrant evaluation. Despite its beneficial overall effect in the controlled setting of clinical trials, endarterectomy's risk of death and stroke preclude surgery in some patients.5 The North American Symptomatic Carotid Endarterectomy Trial Collaborators1 and Veterans Affairs3 trial posted a perioperative death and/or stroke rate of 5.8% and 6.7%, respectively, despite excluding surgeons whose pretrial endarterectomy complication rates exceeded 6%. Conversely, the European Carotid Surgery Trialists' Collaborative Group2 did not explicitly limit surgeon participation based on complication rates and had a rate of 7.5% for the same end point. Contemporary communitybased audits,6-8 which may be more representative of actual health care delivery, suggest that disability and death from carotid References 1. North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis . N Engl J Med . 1991;325:445-453.Crossref 2. European Carotid Surgery Trialists' Collaborative Group. MRC European Carotid Surgery Trial: interim results for symptomatic patients with severe (70%-99%) or mild (0-29%) carotid stenosis . Lancet . 1991;337:1235-1243.Crossref 3. Mayberg MR, Wilson SE, Yatsu F, et al. Carotid endarterectomy and prevention of cerebral ischemia in symptomatic carotid stenosis: Veterans Affairs Cooperative Study Program 309 Trialist Group . JAMA . 1991;266:3289-3294.Crossref 4. Investigators of the Asymptomatic Carotid Atherosclerosis Study (ACAS). Clinical Advisory on Carotid Endarterectomy for Patients With Asymptomatic Carotid Artery Stenosis . Bethesda, Md: National Institute of Neurological Disorders and Stroke Clinical Alert; 1994. 5. Moore WS, Barnett HJM, Beebe HG, et al. Special report: guidelines for carotid endarterectomy: a Multidisciplinary Consensus Statement From the Ad Hoc Committee, American Heart Association . Circulation . 1995;91:566-579.Crossref 6. Brott T, Thalinger K. The practice of carotid endarterectomy in a large metropolitan area . Stroke . 1984;15:950-955.Crossref 7. Brott TG, Labutta RJ, Kempczinsky RF. Changing patterns in the practice of carotid endarterectomy in a large metropolitan area . JAMA . 1986; 255:2609-2612.Crossref 8. Burns RJ, Willoughby JO. South Australian carotid endarterectomy study . Med J Aust . 1991; 154:650-653. 9. McCrory DC, Goldstein LB, Samsa GP, et al. Predicting complications of carotid endarterectomy . Stroke . 1993;24:1285-1291.Crossref 10. Committee on Health Care Issues. Does carotid endarterectomy decrease stroke and death in patients with transient ischemic attacks . Ann Neurol . 1987;22:72-76.Crossref 11. Blaisdell WF, Clauss RH, Galbraith JG, Imperato AM, Wylie EJ. The Joint Study of Extracranial Arterial Occlusion, IV: a review of surgical considerations . JAMA . 1969;209:1889-1895.Crossref 12. Millikan CH, McDowell FH. Treatment of progressing stroke . Stroke . 1981;12:397-409.Crossref 13. Mentzer RM Jr, Finkelmeier BA, Crosby IK, Wellons HA Jr. Emergency carotid endarterectomy for fluctuating neurologic deficits . Surgery . 1981;89:60-66. 14. Meyer FB, Sundt TM Jr, Piepras DG, Sandon BA, Forbes G. Emergency endarterectomy for patients with acute carotid occlusion and profound neurological deficits . Ann Surg . 1986;203:82-89.Crossref 15. Goldstone J, Moore WS. Emergency carotid artery surgery in neurologically unstable patients . Arch Surg . 1976;111:1284-1291.Crossref 16. Sackett DL. Rules of evidence and clinical recommendations on the use of antithrombotic agents . Chest . 1986;89( (suppl) ):2S-3S.Crossref 17. Grines CL, Browne KF, Marco J, et al. A comparison of immediate angioplasty with thrombolytic therapy for acute myocardial infarction . N Engl J Med . 1993;328:673-679.Crossref 18. Fuster V, Badimon L, Badimon JJ, Chesebro JH. The pathogenesis of coronary artery disease and the acute coronary syndromes . N Engl J Med . 1992;326( (pt 1) ):242-250.Crossref 19. Fuster V, Badimon L, Badimon JJ, Chesebro JH. The pathogenesis of coronary artery disease and the acute coronary syndromes . N Engl J Med . 1992;326( (pt 2) ):310-318.Crossref 20. Solis OJ, Roberson GR, Taveras JM, Mohr J, Pessin M. Cerebral angiography in acute cerebral infarction . Rev Interam Radiol . 1977;2:19-25. 21. Fieschi C, Argentino C, Lenzi GL, Sacchett ML, Toni D, Bozzao L. Clinical and instrumental evaluation of patients with ischemic stroke within the first six hours . J Neurol Sci . 1989;91:311-321.Crossref 22. Ferguson R. Getting it right the first time . Am J Neuroradiol . 1990;11:875-877. 23. Jansen C, Ramos LM, van Heesewijk JP, Moll FL, van Gijn J, Ackerstaff RG. Impact of microembolism and hemodynamic changes in the brain during carotid endarterectomy . Stroke . 1994;25:992-997.Crossref 24. The NACPTAR Investigators, Ferguson R, Schwarten D, Purdy P, et al. Restenosis following cerebral percutaneous transluminal angioplasty . Stroke . 1995;26:186. Abstract. 25. Healy DA, Clowes AW, Zierler RE, et al. Immediate and long-term results of carotid endarterectomy . Stroke . 1989;20:1138-1142.Crossref 26. Healy DA, Zierler RE, Nicholls SC, et al. Long-term follow up and clinical outcome of carotid restenosis . J Vasc Surg . 1989;10:662-668.Crossref 27. Zierler RE, Bandyk DF, Thiele BL, Strandness ED. Carotid artery stenosis following endarterectomy . Arch Surg . 1982;117:1408-1412.Crossref 28. Reinmuth OM, Dyken ML. Carotid endarterectomy: bright light at the end of the tunnel . Stroke . 1991;22:835-836.Crossref 29. Hsia DC, Krushat M, Moscoe LM. Epidemiology of carotid endarterectomys among Medicare beneficiaries . J Vasc Surg . 1992;16:201-208.Crossref 30. Pokras R, Dyken ML. Dramatic changes in the performance of endarterectomy for disease of the extracranial arteries of the head . Stroke . 1988; 19:1289-1290.Crossref 31. Dyken ML. Controversies in stroke: past and present . Stroke . 1993:24:1251.Crossref 32. Ferguson RDG, Ferguson JG, Lee LI. Extracranial carotid and vertebral artery stenosis: the future of angioplasty. In: Batjer HH, ed. Cerebrovascular Disease. New York, NY: Raven Press. In press. 33. Kerber CW, Cromwell LD, Leohden OL. Catheter dilatation of proximal stenosis during distal bifurcation endarterectomy . AJNR Am J Neuroradiol . 1980;1:348-349. 34. Mullan S, Duda EE, Patro NAS. Some examples of balloon technology in neurosurgery . J Neurosurg . 1980;52:321-329.Crossref 35. 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Circulation . 1995;92( (suppl) ): I-383. 39. Yadav SS, Roubin GS, Iyer S, et al. Application of lessons learned from cardiac interventional techniques to carotid angioplasty . J Am Coll Cardiol . 1995( (special issue) ):380. Abstract.
Archives of Neurology – American Medical Association
Published: Jul 1, 1996
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