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(Circulation. 1995;91:566-579.)
© 1995 American Heart Association, Inc.
Articles |
Guidelines for Carotid Endarterectomy
A Multidisciplinary Consensus Statement From the Ad Hoc Committee, American Heart Association
Background and Purpose Indications for carotid endarterectomy have engendered considerable debate among experts and have resulted in publication of retrospective reviews, natural history studies, audits of community practice, position papers, expert opinion statements, and finally prospective randomized trials. The American Heart Association assembled a group of experts in a multidisciplinary consensus conference to develop this statement.
Methods A conference was held July 16-18, 1993, in Park City, Utah, that included recognized experts in neurology, neurosurgery, vascular surgery, and healthcare planning. A program of critical topics was developed, and each expert presented a talk and provided the chairman with a summary statement. From these summary statements a document was developed and edited onsite to achieve consensus before final revision.
Results The first section of this document reviews the natural history, methods of patient evaluation, options for medical management, results of surgical management, data from position statements, and results to date of prospective randomized trials for symptomatic and asymptomatic patients with carotid artery disease. The second section divides 96 potential indications for carotid endarterectomy, based on surgical risk, into four categories: (1) Proven: This is the strongest indication for carotid endarterectomy; data are supported by results of prospective contemporary randomized trials. (2) Acceptable but not proven: a good indication for operation; supported by promising but not scientifically certain data. (3) Uncertain: Data are insufficient to define the risk/benefit ratio. (4) Proven inappropriate: Current data are adequate to show that the risk of surgery outweighs any benefit.
Conclusions Indications for carotid endarterectomy in symptomatic
good-risk patients with a surgeon whose surgical morbidity and
mortality rate is less than 6% are as follows. (1) Proven:
one or more TIAs in the past 6 months and carotid stenosis
70% or mild stroke within 6 months and a carotid stenosis
70%; (2) acceptable but not proven: TIAs
within the past 6 months and a stenosis 50% to 69%, progressive
stroke and a stenosis 70%, mild or moderate stroke in the
past 6 months and a stenosis 50% to 69%, or carotid endarterectomy
ipsilateral to TIAs and a stenosis 70% combined with
required coronary artery bypass grafting; (3) uncertain:
TIAs with a stenosis <50%, mild stroke and stenosis <50%, TIAs with
a stenosis <70% combined with coronary artery bypass grafting, or
symptomatic, acute carotid thrombosis; (4) proven
inappropriate: moderate stroke with stenosis <50%, not on
aspirin; single TIA, <50% stenosis, not on aspirin; high-risk patient
with multiple TIAs, not on aspirin, stenosis <50%; high-risk patient,
mild or moderate stroke, stenosis <50%, not on aspirin; global
ischemic symptoms with stenosis <50%; acute dissection, asymptomatic
on heparin. Indications for carotid endarterectomy in asymptomatic
good-risk patients performed by a surgeon whose surgical morbidity and
mortality rate is less than 3% are as follows. (1) Proven:
none. As this statement went to press, the National Institute of
Neurological Disorders and Stroke issued a clinical advisory stating
that the Institute has halted the Asymptomatic Carotid Atherosclerosis
Study (ACAS) because of a clear benefit in favor of surgery for
patients with carotid stenosis 60% as measured by diameter
reduction. When the ACAS report is published, this indication will
be recategorized as proven. (2) acceptable but not
proven: stenosis >75% by linear diameter; (3)
uncertain: stenosis >75% in a high-risk patient/surgeon
(surgical morbidity and mortality rate >3%), combined
carotid/coronary operations, or ulcerative lesions without
hemodynamically significant stenosis; (4) proven
inappropriate: operations with a combined stroke morbidity and
mortality >5%.
Key Words: carotid endarterectomy • stroke • clinical trials • consensus statement • surgery
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