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Clinical Decisionmaking

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Inappropriate use of carotid endarterectomy to prevent stroke has declined over the past few years

The overuse of stroke prevention surgery to open blocked neck arteries (carotid endarterectomy) has dropped significantly over the past 20 years, according to a new study. However, one in ten of these surgeries is still considered inappropriate, that is, they are performed on patients for whom the risks of surgery outweigh the benefits.

Carotid endarterectomy is considered inappropriate for patients who have multiple cardiac risk factors—such as heart disease, heart failure, diabetes, or kidney disease—that actually increase the risk of stroke or death following surgery. Nearly 140,000 carotid endarterectomies are performed each year in the United States at an average total cost per patient for diagnostic tests, surgical procedures, hospitalization, and followup care related to the procedure of about $15,000. Based on the study, about 14,000 of these operations may be performed for inappropriate reasons, according to Ethan A. Halm, M.D., M.P.H., of the Mount Sinai School of Medicine.

In a study that was supported in part by the Agency for Healthcare Research and Quality (HS09754), Dr. Halm and his colleagues reviewed the patient records of carotid endarterectomies performed at six New York hospitals in 1997 and 1998 to see whether the number of inappropriate surgeries had changed since the 1980s, when clinical trials prompted an increase in use of the procedure. At the time, there was also a major shift toward operating on asymptomatic patients.

Although the number of cardiac endarterectomies has doubled since 1981, the proportion of inappropriate surgeries dropped from 32 percent in 1981 to 10.6 percent in 1998. Nearly three-quarters of patients undergoing carotid endarterectomies had no symptoms. Although overall complication rates were low, rates among asymptomatic patients with coexisting medical conditions exceeded recommended thresholds.

See "Revisiting the appropriateness of carotid endarterectomy," by Dr. Halm, Mark R. Chassin, M.D., M.P.P., M.P.H., Stanley Tuhrim, M.D., and others, in the June 2003 Stroke 34(6), pp. 1464-1471.

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