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Invited Commentary
July 26, 2010

The Good, the Bad, and the About-to-Get Ugly: National Trends in Carotid Revascularization: Comment on “Geographic Variation in Carotid Revascularization Among Medicare Beneficiaries, 2003-2006”

Arch Intern Med. 2010;170(14):1225-1227. doi:10.1001/archinternmed.2010.223

The history of carotid endarterectomy (CEA) is a fascinating good news, bad news story. Wide geographic variations in the use of CEA have been noted for 3 decades, though its popularity has been cyclical. The use of CEA doubled in the early 1980s, but then dropped in half following reports of frequent complications1 and a national Medicare study reporting that one-third of CEAs were inappropriate.2 Subsequently, multinational randomized controlled trials (RCTs) found that, among carefully selected patients and surgeons, CEA reduced the risk of stroke and death compared with medical therapy. Symptomatic patients (with recent carotid stroke or transient ischemic attack), showed great benefit (absolute risk reduction in stroke of 8% per year) over 2 to 3 years.3 Asymptomatic patients had more modest benefit (absolute risk reduction of 1% per year) over 5 years.4,5

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