Risky Stroke-Preventing Surgery Still Common
By Ed Edelson, HealthScoutNews Reporter
HealthScoutNews — More than 10 percent of the 130,000 artery-clearing operations called carotid endarterectomies done in the United States every year would be better left undone, a study estimates.
For those 14,000 patients, the potential risks outweigh the benefits, says a report in the May 9 online issue of Stroke.
But there’s some good news, says study author Dr. Ethan A. Halm, an assistant professor of health policy and medicine at Mount Sinai School of Medicine in New York City: The number of inappropriate operations is down by two-thirds since the 1980s, and there are some questions patients can ask to check on whether the operation is right for them.
A carotid endarterectomy is done to prevent a stroke. The surgeon removes plaque from the arteries leading to the brain, fatty deposits that could eventually block a blood vessel and kill part of the brain.
“This kind of surgery was very controversial in the 1970s and 1980s,” Halm explains. “Enthusiasm for it dampened when a RAND Corporation [study] showed that the risk of patients dying was much higher than people thought. Then the National Institutes of Health invested millions of dollars in controlled studies to clarify who benefits and who doesn’t. The NIH sent out several alerts, and now we have gold standard data on who benefits and who doesn’t.”
In general, the operation is not appropriate for patients who have no symptoms indicating they are at high risk of a stroke, those who do not have significant narrowing of the carotid artery, the main blood vessel to the brain, and those who have several serious medical conditions, the guidelines say.
A large 1981 study of Medicare patients that used those criteria found that 35 percent of the operations were judged to be appropriate, 32 percent inappropriate, and 32 percent uncertain. The new study, which looked at 2,214 patients who had surgery in 1997 and 1998, finds that 84.9 percent of the operations were appropriate, 4.5 percent uncertain and only 10.6 percent were done for inappropriate reasons.
The two big reasons to call an operation inappropriate were the presence of other serious conditions in the patient (44.6 percent of the cases) or the fact that the carotid artery had not narrowed enough to warrant surgery, the report says.
One striking finding was the unusually high rate of serious problems for patients who had both an endarterectomy and bypass surgery, a combination deemed necessary because fatty deposits were blocking both the carotid artery and blood vessels of the heart. More than 10 percent of those patients died or had a stroke within 30 days after the operation, the study finds.
“The complication rate is quite high, and this combined procedure should not be done,” says Dr. Mark J. Alberts, a professor of neurology at Northwestern University and a spokesman for the American Heart Association.
Inappropriate operations can be avoided if the patient is assessed “by a multidisciplinary team, not only the surgeon but also a neurologist and an internist or cardiologist,” Alberts says.
The patient’s voice should be heard, too, Halm says. “People need to feel comfortable asking their doctor or the surgeon what the risk of complications is,” he says. While the controlled trials included only relatively healthy and younger patients, “in the real world there are a lot of older patients with multiple problems being operated on,” he says. “Patients need to ask their doctors if their mix of health problems is too risky for them to have the surgery.”
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On the Net:
National Institute of Neurological Diseases and Stroke
Mount Sinai School of Medicine
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