We fully commiserate with Dr Toole's understandable reaction to our consensus statement concerning carotid surgery in asymptomatic carotid stenosis,1 and we agree that the Asymptomatic Carotid Atherosclerosis Study (ACAS) represents a clinical trial conducted with a high standard of care. This makes the results of the ACAS all the more disappointing.
Dr Toole rightly indicates that individual patient care is our goal, and not that of anonymous populations so beloved of epidemiologists. One purpose of a practice guideline or consensus statement, however, is to do just that—help physicians relate available evidence to individual patients. Criticism of the above average skill of the ACAS surgeons may be ironic but is a critical issue when the risk-benefit ratio of intervention is so marginal and the availability of these surgeons so limited. Indeed, if Dr Toole is correct, should we consider ourselves in a state of public health crisis given the enormous
Perry JR, Norris JW. Asymptomatic Carotid Artery Stenosis. Arch Neurol. 1997;54(7):799-800. doi:10.1001/archneur.1997.00550190005002