Operative mortality following carotid endarterectomy.

Operative Mortality Following Carotid Endarterectomy To the Editor: I read with great interest the editorial by Dr. Gary G. Ferguson in the May-June 1982 issue of STROKE, Volume 13, p. 287, entitled "Intraoperative Monitoring and Internal Shunts: Are They Necessary in Carotid Endarterectomy?". I was dismayed, however, by the manner in which he displayed our data in the table using his reference #12, which makes our data appear to be the worst of all that quoted, which is simply not the case. The article of ours which he quoted is 12 years out of date at present and includes mortality and morbidity figures since our study began in 1957. At that time we were operating on acute and progressing strokes and were not using shunts. This is, therefore, not a true representation of the situation as it exists today. In the last 17 years we have used general anesthesia, routine shunts, and have avoided operation on acute and progressing strokes in a series of more than 1300 operations. Our overall operative mortality has been 1.4%, being 1.1% for TIAs and zero for asymptomatic bruits. Proper classification of patients has to be used when carotid mortality data are reported. Likewise, in a series of 516 recent operations on patients with TIAs and asymptomatic bruits, all operated upon by the same surgeon, our total incidence of mild and severe permanent deficits has been 1.36%. Granted that selective shunting properly used gives excellent results, I continue to use and advocate routine shunting. Dr. Ferguson states, "In fact, the best results have been reported by those who avoid shunts." He quotes Baker, et al, in this category as having a stroke rate of 1.6% with no shunting. However, in the article by Baker, et al, if one looks at the data, one sees that when operation is performed with the contralateral carotid occluded and no shunt is used, the stroke rate was 3 in 34 patients, or 8.8%. In our own series of 142 such operations done with routine shunting, there was one permanent neurologic deficit, or an incidence of 0.7%. The advocacy of no shunting at all times is unacceptable. One must know and use the proper indications for shunting when advocating selective shunting if best results are to be obtained. Thank you very much. Jesse £ . Thompson, M.D. Baylor Medical Plaza, Dallas, Texas 75246