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Objective: To evaluate therapy with aspirin plus dipyridamole in reducing restenosis after carotid endarterectomy.Patients: A total of 163 patients having 175 surgical carotid endarterectomies.Intervention: Eighty-three patients (90 endarterectomies) were randomly assigned to receive oral aspirin, 325 mg, plus dipyridamole, 75 mg, beginning 12 hours preoperatively, followed by a second dose administered within 8 hours after the operation, and given three times daily thereafter for 1 year. Eighty patients (85 endarterectomies) received placebo medication that was identical in appearance to the study drugs.Measurements: After the adequacy of the surgical procedure was confirmed by intraoperative angiography, restenosis at the endarterectomy sites was evaluated using serial duplex ultrasound studies before hospital discharge and at 3-month intervals postoperatively for 1 year.Results: Based on the time for developing identifiable restenosis and on efficacy analysis, greater than 50% restenosis developed in 11 operated vessels (16%) in the treated group and in 10 arteries (14%) in the placebo group, yielding an observed risk increase of 14% (95% CI, -52% to 167%; P greater than 0.2). By intention-to-treat analysis, greater than 50% restenosis developed in 16 of 90 operated vessels in treated patients and in 10 of 85 arteries in patients receiving placebo (26% for the treated group and 12% for the placebo group; P = 0.18, Mantel-Haenszel statistic), representing an observed risk increase of 110% (CI, -5% to 365%). Similar differences were observed for greater than 20% restenosis and for the comparison of patients rather than operated vessels by either intention-to-treat or efficacy analyses.Conclusions: Because therapy not only failed to reduce carotid restenosis but may have actually increased its frequency, treatment with aspirin plus dipyridamole probably has no clinically important benefit on restenosis in patients having carotid endarterectomy. [ABSTRACT FROM AUTHOR]

Objective: To determine whether the complication or death rate from carotid endarterectomy can be predicted from hospital and physician structural variables, such as the hospital's teaching status or the number of endarterectomies done by the surgeon per year.Design: Survey of medical records. After controlling for the severity of the patient's condition on the basis of data in the medical record at the time of the endarterectomy, regression analyses were used to predict the postoperative stroke, heart attack, and 30-day death rate as a function of patient, physician, and hospital characteristics.Setting: Three geographic areas (states or large parts of states; average population, 3 million) in the United States.Patients: Random sample of 1302 patients 65 years of age or older having carotid endarterectomy in 1981.Intervention: Carotid endarterectomy.Measurements and Main Results: Of 1302 patients, 11.3% had a postoperative stroke or heart attack or died within 30 days of the operation. Patient age, race, income, and gender; physician volume, board certification status, and age; and hospital size, for-profit status, ownership, and teaching status were not significantly related to the postoperative complication or death rate. If the surgeon was a graduate of a foreign, but not a Western European or Canadian, medical school, however, the average complication or death rate rose from 10.4% to 19.6% (P less than 0.05).Conclusions: The effectiveness of carotid endarterectomy depends heavily on its complication rate. Because complications after surgery cannot, in general, be predicted from structural variables, referring physicians cannot rely solely on the surgeon's experience and qualifications when recommending a carotid endarterectomy. The surgeon's and the hospital's actual postoperative complication and death rate should be considered. [ABSTRACT FROM AUTHOR]

Study Objective: To evaluate the usefulness of doing carotid endarterectomy in patients with symptomatic or asymptomatic carotid artery disease.Design: Synthesis and summarization of data on the untreated course of cerebrovascular disease, and review of selected evidence and expert opinion on the risks and benefits of endarterectomy and medical therapy.Main Results: There is a large body of data related to the untreated course of cerebrovascular disease, the efficacy of aspirin in patients with transient ischemic attacks, and the comparative responsiveness to surgery of symptomatic patients with different presentations. Randomized trials in progress will increase the knowledge about the effects of aspirin in asymptomatic patients, the comparative efficacy of aspirin and endarterectomy in asymptomatic and symptomatic patients, and the factors that influence surgical risk. Clinicians and investigators wish to define a more limited and precise set of indications for carotid endarterectomy. In setting standards, attention has properly focussed on "maximum acceptable complication rates," native stroke risk, and surgical efficacy for patients with different clinical presentations. Illustrative, acceptable surgical mortality rates are less than 1%, and stroke-related morbidity is less than 3% for patients who have had a transient ischemic attack; surgical mortality and stroke-related morbidity are less than 2% for patients with asymptomatic carotid stenosis. Medical comorbidity and angiographic findings are important factors affecting specific recommendations.Conclusions: Data from ongoing clinical trials will provide a more scientific foundation for recommendations about when to do carotid endarterectomy. Current evidence suggests that fewer endarterectomies should be done, and those on the basis of a more precise set of indications. Clinicians should consider the clinical presentation, the patient's comorbidity and native stroke risk, angiographic findings, and the experience of the surgical team. [ABSTRACT FROM AUTHOR]

Major advances are being made in our understanding of the pathophysiology of ischemic stroke. In the past 25 years anticoagulation, carotid endarterectomy, and antiplatelet aggregation agents, along with less well-accepted therapies, have been introduced for the management of this complex disorder. Also, noninvasive diagnostic methods have been developed for evaluating these patients. This article reviews the pathophysiology of cerebral ischemia and the data on the effectiveness of the various therapies advocated for its management. [ABSTRACT FROM AUTHOR]

Analyzes the option of surgical treatment called endarterectomy for patients with asymptomatic carotid disease. Role of the Asymptomatic Carotid Artery Study (ACAS); Percentage of relative risk reduction; Zero impact of surgery on incidence of disabling strokes.

Compares the results of carotid endarterectomy combined with aspirin and risk reduction against aspirin and risk reduction in the prevention of ipsilateral stroke among asymptomatic patients with carotid artery stenosis. Arteriographic complication rate; Benefits of surgery; Proposal on surgery recommendation.

Discusses the indications for performing carotid endarterectomy. Benefits from carotid endarterectomy; Rationale for performing carotid endarterectomy for posterior circulation symptoms; Factors that need to be considered before doing endarterectomy.

Editorial. Focuses on the conditions under which intravenous digital subtraction angiography would be a cost-effective addition in the diagnosis of cerebrovascular disease. Physician acceptance of intravenous digital subtraction angiography as a substitute for carotid arteriography; Cost-effectiveness ratios for two basic clinical protocols; Technical limitations that restricted the diagnostic capabilities of carotid intravenous.

Focuses on surgical treatment of carotid and vertebral artery disease. Stenosis of the carotid artery; Carotid artery kinks; Studies and surgery after infarction.

Discusses carotid disease and impaired cognition. Findings of Johnston and colleagues in the prevalence of impaired cognition in patients with high-grade stenosis of the left internal carotid artery but not the right internal carotid; Need for more inclusive studies before accepting this finding as evidence that carotid stenosis causes functionally important cognitive impairment; Example of two clinical trails, in USA and Europe; Alternative to carotid endarterectomy as carotid stenting; Recommendation of medical prophylaxis for most persons with asymptomatic carotid disease.

A correction to the article "Screening for asymptomatic carotid artery stenosis: U.S. Preventive Services Task Force recommendation statement" that was published in a 2014 issue is presented.

Editorial. Reports on the possibility of surgery for asymptomatic carotid stenosis. Findings of Asymptomatic Carotid Artery Study (ACAS).

Focuses on problems in biomedical research. Difficulties in the status of fusion of the lumbar spine in patients where there is intervertebral disk disease; Significance of knowing carotid artery surgery and the surgical restoration of vertebral arteries.