Long-term follow-up of surgically managed carotid bifurcation atherosclerosis. Justification for an aggressive approach.

To document the efficacy of our aggressive surgical approach to stroke prevention, we compiled follow-up data on 619 patients undergoing 993 carotid endarterectomies at our institution since 1970. Following carotid endarterectomy, crude annual stroke incidence, including perioperative strokes (2.2%), was 1.9%. In our symptomatic patients crude annual stroke incidence, including perioperative strokes (2.7%), was 2.1%. This is superior to the annual stroke incidence seen in patients on "optimal" medical therapy as defined by the Canadian Cooperative Study (4.6% in men), the AICLA Study (2.9%), the American Multicenter Trial (8%), and the Canadian- American Cooperative Trial (approximately 5%). In our asymptomatic patients, crude annual stroke incidence, including perioperative strokes (1.1%), was 1.4%. This is superior to nonsurgical therapy for asymptomatic patients with hemodynamically significant or more than 75% stenoses as reported by the Mayo Clinic (3.4%) or Chambers and Norris (2.7%). An aggressive surgical approach to carotid bifurcation atherosclerosis is superior to nonsurgical therapy in symptomatic and selected asymptomatic patients if low perioperative mortality/stroke morbidity rates are achieved.