ABSTRACT
By the early 1980s there were over 100,000 procedures per year in the USA
alone (35). However, at this point in time, there was no evidence from ran-
domized controlled trials that the operation was of any value. This
prompted several eminent clinicians to question the widespread use of the
operation in the early 1980s (36-39) which led to a fall in the number of
operations being done and set the scene for a number of large, randomized
controlled trials. There have been five randomized controlled trials of carotid endarter-
ectomy for symptomatic carotid stenosis (24,25,40-42). The first two studies
were relatively small and did not produce reliable results (40,41). The larger
VA Cooperative Symptomatic Carotid Stenosis Trial (VA #309) reported a
non-significant trend in favor of surgery (42), but was stopped in 1991 when
the European Carotid Surgery Trial (ECST) and the North American
Symptomatic Carotid Endarterectomy Trial (NASCET) demonstrated a
clear reduction in the overall risk of stroke in operated patients with recently
symptomatic severe (70-99%) carotid stenosis (24,25). The final report from
the NASCET and a subsequent pooled analysis of individual patient data
from all trials showed that endarterectomy was also of benefit in patients
with recently symptomatic 50-69% stenosis (43,44). However, other research
done in parallel has shown that the benefit also depends to a significant extent
on other clinical characteristics (45-47).
