Public health impact of carotid endarterectomy

Despite the completion of several multi-center clinical trials comparing medical management and carotid endarterectomy, there is still controversy as to when carotid endarterectomy is appropriate. The volume of this surgery appears to be increasing. However, available performance data indicate that the surgical proficiency required for the clinical trials is not achieved uniformly in actual practice. Therefore, benefits of carotid endarterectomy, when considered from a public health perspective, are limited by the following: (1) endarterectomy is an expensive stroke prevention modality; (2) endarterectomy addresses the needs of only a relatively small subset of stroke patients, and (3) endarterectomy for asymptomatic patients, without clearer evidence that these individuals benefit, may decrease the cost-effectiveness of this surgical procedure.