Public health impact of carotid endarterectomy

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