Fewer patients undergoing stroke prevention surgery for wrong reasons

Stroke prevention

A new study has found a drop in the number of patients undergoing the most commonly used stroke prevention surgery, carotid endarterectomy, for inappropriate reasons. Researchers are crediting the drop to highly publicized randomized controlled trials (RCTs) that clarified the appropriate use of the surgery. The researchers' findings are published in the January 16, 2007, issue of Neurology , the scientific journal of the American Academy of Neurology.

The New York Carotid Artery Surgery (NYCAS) study evaluated the appropriateness of 9,588 carotid endarterectomy surgeries performed on elderly patients in New York state. Carotid endarterectomy is a surgical procedure that involves opening up the artery in the neck that supplies blood to the brain and removing harmful plaque build-up that can cause a stroke.

The NYCAS study found the rate of inappropriate carotid endarterectomy surgeries among the elderly dropped substantially from 32 percent in the landmark RAND Health Services Utilization Study in 1981 before the RCTs to 8.6 percent in the present study's evaluation of New York cases in the period after publication of the trials. It was the RAND study's findings that prompted several larger international clinical trials to clarify when it is appropriate to perform a carotid endarterectomy.

"Though RCTs are time-consuming, expensive, and logistically challenging, our findings suggest that they played a role in improving the appropriate use of carotid endarterectomy," said the study's author Ethan Halm, MD, MPH, an Associate Professor at The Mount Sinai School of Medicine in New York, New York.

The most common reason the procedures were determined to be inappropriate in the current study was because patients with no symptoms from the blocked arteries were at high risk of surgical complications due to the presence of several other major medical problems. This subgroup of patients had more than twice the risk of death or stroke due to the surgery compared to those without other diseases.

"The good news is following the large public investment in medical research on who should undergo carotid endarterectomy, there's been a large reduction in the number of patients undergoing the procedure for inappropriate reasons. The bad news is there's been a shift towards operating predominantly on patients with no symptoms from the blocked arteries where the benefit from surgery is lower and is reduced further for patients with other medical conditions," said Halm.