Which asymptomatic patients should have carotid endarterectomy?

Carotid endarterectomy for asymptomatic very-high-grade stenosis has been shown to be of clear benefit when compared with best medical treatment in recent prospective randomized studies. However, the benefit of carotid endarterectomy in these trials has been less than most vascular surgeons predicted based on prior nonrandomized studies. Furthermore, vascular surgeons often see patients who do not fit the inclusion criteria for any of the prospective randomized trials and whose potential benefit from endarterectomy may be different from that observed in those trials. Medical comorbidities or other patient characteristics that suggest even small increases in risk for carotid endarterectomy may negate the marginal benefit of the procedure in asymptomatic patients. Potential benefit is also highly dependent on surgeon-specific and hospital-specific perioperative morbidity and mortality. This article addresses some of the factors that may alter the potential benefit of carotid endarterectomy and the implications with respect to recommendations for or against carotid endarterectomy in the individual patient.