Cerebrovascular accident (CVA) is the third leading cause of death and affects over 500 000 patients per year in the USA. The disability suffered by stroke victims places an enormous financial burden on the healthcare system. Carotid endarterectomy, an operation designed to prevent stroke, is the most common vascular procedure performed today. Over the last 15 years, the indications for carotid endarterectomy have been firmly established. Three large multicenter trials published in 1991 conclusively demonstrated the beneficial effects of surgical therapy of cerebrovascular disease over medical therapy in symptomatic patients. Endarterectomy for asymptomatic carotid stenosis in two large multicenter trials also showed a smaller but significant benefit of carotid endarterectomy for stroke prevention. Indications are not as conclusive and are considered on an individual basis for patients with stroke-in-evolution or with completed CVA and carotid stenosis. Since carotid endarterectomy is a preventive operation, the benefits from these studies apply to centers where the perioperative stroke rate is under 3%.

Carotid endarterectomy can be performed under local, regional, or general anesthesia, but we prefer local anesthesia and selective shunting. General anesthesia is reserved for those patients who may be anxious or in whom we anticipate difficult anatomy. The operation takes approximately two hours and involves a longitudinal incision in the lateral neck. The stages of the procedure are gentle exposure of the carotid bifurcation, heparinization, cross-clamping of the vessels, shunting if necessary, removal of the plaque, and usually closure with a Dacron patch angioplasty.