Skip to main content
Annals of Surgery logoLink to Annals of Surgery
. 1986 Aug;204(2):163–171. doi: 10.1097/00000658-198608000-00010

Surgical versus nonoperative treatment of asymptomatic carotid stenosis. 290 patients documented by intravenous angiography.

N R Hertzer, R A Flanagan Jr, E G Beven, P J O'Hara
PMCID: PMC1251257  PMID: 3527089

Abstract

From 1980 through 1982, intravenous extracranial digital subtraction angiography (DSA) was performed in 6684 patients at the Cleveland Clinic. Of these, 290 previously unoperated patients had asymptomatic carotid stenosis exceeding 50% of lumen diameter on unequivocal DSA studies. Either the presence or the absence of carotid bruits substantially misrepresented the severity of angiographic stenosis on approximately 30% of sides. Nonoperative management was employed in 195 patients, including 104 (53%) who received antiplatelet therapy, while another group of 95 patients underwent prophylactic carotid endarterectomy. During mean follow-up intervals of 33-38 months, surgical treatment significantly reduced the cumulative incidence of subsequent neurologic events in men (p = 0.05). Statistically unconfirmed trends also suggested that carotid endarterectomy tended to prevent late strokes in subsets of patients with greater than 70% stenosis or bilateral carotid lesions. The overall stroke rate for women was higher in the surgical group (p = 0.03), in part because of their unusual risk for perioperative complications (9%) in this particular series.

Full text

PDF
163

Images in this article

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Barnes R. W., Nix M. L., Sansonetti D., Turley D. G., Goldman M. R. Late outcome of untreated asymptomatic carotid disease following cardiovascular operations. J Vasc Surg. 1985 Nov;2(6):843–849. [PubMed] [Google Scholar]
  2. Barnett H. J., Plum F., Walton J. N. Carotid endarterectomy--an expression of concern. Stroke. 1984 Nov-Dec;15(6):941–943. doi: 10.1161/01.str.15.6.941. [DOI] [PubMed] [Google Scholar]
  3. Brott T., Thalinger K. The practice of carotid endarterectomy in a large metropolitan area. Stroke. 1984 Nov-Dec;15(6):950–955. doi: 10.1161/01.str.15.6.950. [DOI] [PubMed] [Google Scholar]
  4. Busuttil R. W., Baker J. D., Davidson R. K., Machleder H. I. Carotid artery stenosis - hemodynamic significance and clinical course. JAMA. 1981 Apr 10;245(14):1438–1441. doi: 10.1001/jama.245.14.1438. [DOI] [PubMed] [Google Scholar]
  5. CUTLER S. J., EDERER F. Maximum utilization of the life table method in analyzing survival. J Chronic Dis. 1958 Dec;8(6):699–712. doi: 10.1016/0021-9681(58)90126-7. [DOI] [PubMed] [Google Scholar]
  6. Chambers B. R., Norris J. W. The case against surgery for asymptomatic carotid stenosis. Stroke. 1984 Nov-Dec;15(6):964–967. doi: 10.1161/01.str.15.6.964. [DOI] [PubMed] [Google Scholar]
  7. Connolly J. E., Brownell D. A., Levine E. F., McCart P. M. Accuracy and indications of diagnostic studies for extracranial carotid disease. Arch Surg. 1985 Nov;120(11):1229–1232. doi: 10.1001/archsurg.1985.01390350015004. [DOI] [PubMed] [Google Scholar]
  8. Cooperman M., Martin E. W., Jr, Evans W. E. Significance of asymptomatic carotid bruits. Arch Surg. 1978 Nov;113(11):1339–1340. doi: 10.1001/archsurg.1978.01370230129016. [DOI] [PubMed] [Google Scholar]
  9. David T. E., Humphries A. W., Young J. R., Beven E. G. A correlation of neck bruits and arteriosclerotic carotid arteries. Arch Surg. 1973 Nov;107(5):729–731. doi: 10.1001/archsurg.1973.01350230081016. [DOI] [PubMed] [Google Scholar]
  10. Durward Q. J., Ferguson G. G., Barr H. W. The natural history of asymptomatic carotid bifurcation plaques. Stroke. 1982 Jul-Aug;13(4):459–464. doi: 10.1161/01.str.13.4.459. [DOI] [PubMed] [Google Scholar]
  11. Dyken M. L., Pokras R. The performance of endarterectomy for disease of the extracranial arteries of the head. Stroke. 1984 Nov-Dec;15(6):948–950. doi: 10.1161/01.str.15.6.948. [DOI] [PubMed] [Google Scholar]
  12. Easton J. D., Sherman D. G. Stroke and mortality rate in carotid endarterectomy: 228 consecutive operations. Stroke. 1977 Sep-Oct;8(5):565–568. doi: 10.1161/01.str.8.5.565. [DOI] [PubMed] [Google Scholar]
  13. Hertzer N. R., Arison R. Cumulative stroke and survival ten years after carotid endarterectomy. J Vasc Surg. 1985 Sep;2(5):661–668. [PubMed] [Google Scholar]
  14. Hertzer N. R., Avellone J. C., Farrell C. J., Plecha F. R., Rhodes R. S., Sharp W. V., Wright G. F. The risk of vascular surgery in a metropolitan community. With observations on surgeon experience and hospital size. J Vasc Surg. 1984 Jan;1(1):13–21. [PubMed] [Google Scholar]
  15. Hertzer N. R., Flanagan R. A., Jr, Beven E. G., O'Hara P. J. Surgical versus nonoperative treatment of symptomatic carotid stenosis. 211 patients documented by intravenous angiography. Ann Surg. 1986 Aug;204(2):154–162. doi: 10.1097/00000658-198608000-00009. [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Heyman A., Wilkinson W. E., Heyden S., Helms M. J., Bartel A. G., Karp H. R., Tyroler H. A., Hames C. G. Risk of stroke in asymptomatic persons with cervical arterial bruits: a population study in Evans County, Georgia. N Engl J Med. 1980 Apr 10;302(15):838–841. doi: 10.1056/NEJM198004103021504. [DOI] [PubMed] [Google Scholar]
  17. Humphries A. W., Young J. R., Santilli P. H., Beven E. G., deWolfe V. G. Unoperated, asymptomatic significant internal carotid artery stenosis: a review of 182 instances. Surgery. 1976 Dec;80(6):695–698. [PubMed] [Google Scholar]
  18. Imparato A. M., Riles T. S., Mintzer R., Baumann F. G. The importance of hemorrhage in the relationship between gross morphologic characteristics and cerebral symptoms in 376 carotid artery plaques. Ann Surg. 1983 Feb;197(2):195–203. doi: 10.1097/00000658-198302000-00012. [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Johnson J. M., Kennelly M. M., Decesare D., Morgan S., Sparrow A. Natural history of asymptomatic carotid plaque. Arch Surg. 1985 Sep;120(9):1010–1012. doi: 10.1001/archsurg.1985.01390330022004. [DOI] [PubMed] [Google Scholar]
  20. Kartchner M. M., McRae L. P. Noninvasive evaluation and management of the "asymptomatic" carotid bruit. Surgery. 1977 Dec;82(6):840–847. [PubMed] [Google Scholar]
  21. Krupski W. C., Effeney D. J., Goldstone J., Deuel M., Webb R. L., Etheredge S. N., Ehrenfeld W. K., Stoney R. J. Carotid endarterectomy in a metropolitan community: comparison of results from three institutions. Surgery. 1985 Sep;98(3):492–499. [PubMed] [Google Scholar]
  22. Lee E. T., Desu M. M. A computer program for comparing K samples with right-censored data. Comput Programs Biomed. 1972 Nov;2(4):315–321. doi: 10.1016/0010-468x(72)90019-0. [DOI] [PubMed] [Google Scholar]
  23. Lusby R. J., Ferrell L. D., Ehrenfeld W. K., Stoney R. J., Wylie E. J. Carotid plaque hemorrhage. Its role in production of cerebral ischemia. Arch Surg. 1982 Nov;117(11):1479–1488. doi: 10.1001/archsurg.1982.01380350069010. [DOI] [PubMed] [Google Scholar]
  24. Moore D. J., Miles R. D., Gooley N. A., Sumner D. S. Noninvasive assessment of stroke risk in asymptomatic and nonhemispheric patients with suspected carotid disease. Five-year follow-up of 294 unoperated and 81 operated patients. Ann Surg. 1985 Oct;202(4):491–504. doi: 10.1097/00000658-198510000-00009. [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Moore D. J., Sheehan M. P., Kolm P., Russell J. B., Sumner D. S. Are strokes predictable with noninvasive methods: a five-year follow-up of 303 unoperated patients. J Vasc Surg. 1985 Sep;2(5):654–660. [PubMed] [Google Scholar]
  26. O'Donnell T. F., Jr, Erdoes L., Mackey W. C., McCullough J., Shepard A., Heggerick P., Isner J., Callow A. D. Correlation of B-mode ultrasound imaging and arteriography with pathologic findings at carotid endarterectomy. Arch Surg. 1985 Apr;120(4):443–449. doi: 10.1001/archsurg.1985.01390280037009. [DOI] [PubMed] [Google Scholar]
  27. Panel debate. Part I. Advocates in vascular controversies. Surgery. 1984 Jun;95(6):739–752. [PubMed] [Google Scholar]
  28. Riles T. S., Lieberman A., Kopelman I., Imparato A. M. Symptoms, stenosis, and bruit: interrelationships in carotid artery disease. Arch Surg. 1981 Feb;116(2):218–220. doi: 10.1001/archsurg.1981.01380140064014. [DOI] [PubMed] [Google Scholar]
  29. Roederer G. O., Langlois Y. E., Jager K. A., Primozich J. F., Beach K. W., Phillips D. J., Strandness D. E., Jr The natural history of carotid arterial disease in asymptomatic patients with cervical bruits. Stroke. 1984 Jul-Aug;15(4):605–613. doi: 10.1161/01.str.15.4.605. [DOI] [PubMed] [Google Scholar]
  30. Rutkow I. M., Ernst C. B. An analysis of vascular surgical manpower requirements and vascular surgical rates in the United States. J Vasc Surg. 1986 Jan;3(1):74–83. doi: 10.1067/mva.1986.avs0030074. [DOI] [PubMed] [Google Scholar]
  31. Rutkow I. M., Ernst C. B. Vascular surgical manpower. Too much? Enough? Too little? Unknown? Arch Surg. 1982 Dec;117(12):1537–1542. doi: 10.1001/archsurg.1982.01380360013004. [DOI] [PubMed] [Google Scholar]
  32. Slavish L. G., Nicholas G. G., Gee W. Review of a community hospital experience with carotid endarterectomy. Stroke. 1984 Nov-Dec;15(6):956–959. doi: 10.1161/01.str.15.6.956. [DOI] [PubMed] [Google Scholar]
  33. Thompson J. E., Patman R. D., Talkington C. M. Asymptomatic carotid bruit: long term outcome of patients having endarterectomy compared with unoperated controls. Ann Surg. 1978 Sep;188(3):308–316. doi: 10.1097/00000658-197809000-00005. [DOI] [PMC free article] [PubMed] [Google Scholar]
  34. Warlow C. Carotid endarterectomy: does it work? Stroke. 1984 Nov-Dec;15(6):1068–1076. doi: 10.1161/01.str.15.6.1068. [DOI] [PubMed] [Google Scholar]
  35. Wolf P. A., Kannel W. B., Sorlie P., McNamara P. Asymptomatic carotid bruit and risk of stroke. The Framingham study. JAMA. 1981 Apr 10;245(14):1442–1445. [PubMed] [Google Scholar]

Articles from Annals of Surgery are provided here courtesy of Lippincott, Williams, and Wilkins

RESOURCES