Carotid endarterectomy before and after publication of randomized controlled trials

Background: In 1991, the European Carotid Surgery Trial (ECST) and the Nort h American Symptomatic Carotid Endarterectomy Trial (NASCET) demonstrated t hat carotid endarterectomy (CEA), in addition to best medical therapy, sign ificantly reduces ipsilateral stroke in patients with high-grade (70 per ce nt or more) carotid artery stenosis compared with best medical therapy alon e. In 1995, the Asymptomatic Carotid Atherosclerosis Study demonstrated tha t CEA was of benefit in asymptomatic patients with stenosis greater than 60 per cent. The aim of this paper was to examine how the practice and outcom e of CEA have changed since publication of these data. Methods: A prospectively gathered computerized database comprising 634 cons ecutive CEAs was studied. Two time intervals were analysed: 1975-1991 inclu sive (17 years) and 1 January 1992 to 1 May 1998 (6 years 4 months). Results: Since 1991, there has been a fourfold increase in the number of CE As performed annually for symptomatic disease. CEA is now performed almost exclusively for high-grade (more than 70 per cent) stenosis. There has been a significant reduction in the total peri-operative neurological event rat e (12.5 versus 5.9 per cent, P < 0.05), and the 30-day combined major strok e (Rankin grade 3-5) and mortality rate has fallen to 2.0 per cent. The num ber of patients who have CEA for asymptomatic disease remains small with 16 of 30 being randomized within the Asymptomatic Carotid Surgery Trial. Conclusion: Publication of ECST and NASCET data has been associated with a major increase in the number of CEAs performed for symptomatic disease in t his unit. Despite a greater proportion. of highrisk patients, the results h ave improved progressively.