Concerns regarding carotid endarterectomy guidelines.

Concerns Regarding Carotid Endarterectomy Guidelines To the Editor: We were surprised to read the rather unequivocal endorsement1 by the American Heart Association writing group of carotid endarterectomy (CE) for asymptomatic stenosis of greater than 60%. This position does not represent the viewpoint of all stroke neurologists or surgeons, and some professional groups have recently come to the exact opposite conclusion, not recommending CE for asymptomatic stenosis.2 The writing group states that CE is beneficial if the surgical complication rate is less than 3%. Current evidence indicates that CE complication rates are not being closely monitored at US hospitals.3 A recent study found that the surgical complication rates were either unknown or not being monitored at over 50% of teaching hospitals in the United States.4 In the “real world” of CE practice, it is unlikely that a complication rate this low can be uniformly achieved, and a 1991 analysis of Medicare data found that the death rate associated with CE was 2.3%.5 In addition, we and others have concerns that the Asymptomatic Carotid Atherosclerosis Study (ACAS) results cannot be generalized.6–9 Only 4% of the eligible patients were entered into the study.10 In addition, 29% of the surgeons who applied for participation in the trial were either rejected or did not complete the credentialing process.11 Thus, in the ideal setting for producing a positive surgical result (namely, combining low-surgicalrisk patients with surgeons vetted for their excellence), a statistically significant result was obtained, which may not be clinically meaningful to all clinicians. Finally, for full disclosure, it would be of interest to know how many members of the writing group were actual ACAS participants. This may affect the panel’s objectivity, and we would suggest that when controversial studies are involved, future writing groups should include a balance between study participants and nonparticipants.