Review of the primary results and secondary analyses from the European Carotid Surgery Trial (ECST) and the North American Symptomatic Carotid Endarterectomy Trial (NASCET).

Review of 48 ECST and NASCET papers.

The simple assumption that all patients with a symptomatic stenosis >70% benefit from CEA is untenable. Approximately 70–75% will not have a stroke if treated medically. The ECST and NASCET have identified subgroups that should have expedited investigation and surgery (male sex, age >75 years, 90–99% stenosis, irregular plaque, hemispheric symptoms, recurrent events for >6 months, contralateral occlusion, multiple co-morbidity). Accordingly development of local protocols for patient selection/exclusion should involve surgeons and physicians and take account of the local operative risk. The ECST and NASCET have also shown that the ubiquitous “string sign” is not associated with a high risk of stroke, and emergency CEA is unnecessary.

Surgeons must quote their own results and be aware that a high operative risk reduces long-term benefit. Accordingly, in those centres with a higher operative death/stroke rate, some “lower risk” patients should probably be considered for best medical therapy alone. It is hoped that pooling of the ECST and NASCET databases will enable more definitive guidelines to be developed regarding who benefits most from CEA.