Raffaele Ornello, MD

Johal AS, Loftus IM, Boyle JR, Naylor AR, Waton S, Heikkila K, et al. Changing Patterns of Carotid Endarterectomy Between 2011 and 2017 in England: A Population-Based Cohort Study. Stroke. 2019;50:2461–2468.

Carotid endarterectomy (CEA) is effective for secondary stroke prevention in symptomatic patients, while its effectiveness in asymptomatic patients is a matter of debate. Data suggest that CEAs are declining worldwide; however, the reasons for that decline are unclear.

To investigate those possible causes, the authors reviewed data from the English National Vascular Registry in the 2011-2017 period and confirmed a decline of CEAs in both symptomatic and asymptomatic patients. In detail, CEAs performed in asymptomatic patients declined by 63%, from 722 in 2011 to 265 in 2017, while those performed in symptomatic patients declined by 25%, from 4992 in 2011 to 3482 in 2017.

The substantial decline of CEAs performed in asymptomatic patients might be explained by the declining attitude of surgeons towards performing CEA in those patients, while the decline of procedures performed in symptomatic patients is duly paralleled by the authors to the declining incidence of stroke.

The substantial decline of both CEAs and strokes during a 7-year period is relevant and might be explained, at least in part, by the improved primary prevention of atherosclerosis. If further data confirm that conclusion, that would reaffirm the importance of lifestyle and drug interventions to prevent disabling strokes and costly CEA procedures.