Carotid endarterectomy--when to do it, how to do it?

With the completion of the major carotid endarterectomy trials the indications for this procedure can be defined. The procedure, if done by experienced teams, has been shown to improve the chance of stroke free survival in symptomatic and asymptomatic patients with a high-grade stenosis of the internal carotid artery. In asymptomatic patients the risk reduction gained by prophylactic carotid endarterectomy may be small in relation to the risk of coincident factors particularly coronary artery disease. The benefit gained by carotid endarterectomy depends closely on the risk of the procedure itself, and a single little flaw during the management can annulate the benefit of the operation in asymptomatic patients. There are still considerable controversies with regard to peri-operative management and surgical technique, e.g., the necessity of routine pre-operative arteriography has recently been questioned. Quality control programmes become a requirement with the publication of performance standards for carotid endarterectomy. According to a consensus of the American Heart Association, the surgical morbidity/mortality must be less than 6% for symptomatic carotid lesions and less than 3% for asymptomatic lesions. The present review discusses the steps of the pre-operative work-up, the procedure itself and the post-operative management with the aim to identify accepted safety standards as well as areas of uncertainty.