SURGICAL-MANAGEMENT OF CAROTID-ARTERY ATHEROSCLEROTIC DISEASE

Cerebrovascular disease remains an important cause of disability and d eath in the geriatric population. This paper reviews the current state of knowledge with respect to the pathogenesis and medical and surgica l treatment of carotid atherosclerosis. The majority of strokes are pr obably due to embolization from an ulcerated atherosclerotic plaque at the carotid bifurcation rather than from ischemia produced by global reduction in cerebral blood flow related to obstruction of the carotid arteries. Ultrasonography is an appropriate screening examination, bu t most vascular surgeons consider contrast angiography to be essential in the preoperative evaluation. Large clinical trials have evaluated the efficacy of stroke prevention by carotid endarterectomy in symptom atic patients. The North American Symptomatic Carotid Endarterectomy T rial clearly demonstrated a benefit of surgery in stroke prevention as compared with optimal medical therapy after only 18 months of follow- up. The European Carotid Surgery Trial and a VA Cooperative Study prod uced similar conclusions. Much less information is available concernin g the patient with carotid atherosclerosis who has no cerebral symptom s. No convincing evidence that surgery is beneficial has yet been demo nstrated, but a large multicenter clinical trial (Asymptomatic Carotid Atherosclerosis Study) remains in progress.