Re: Mohan IV, Thomas SD. Do patients with asymptomatic carotid stenoses still benefit from surgical intervention? (ANZ J. Surg. 2011; 81: 211-213)
I write in reference to Mohan and Thomas’s article “Do patients with asymptomatic carotid disease still benefit from surgical intervention?”. The word “still” in the title implies that patients once did benefit. They argue that medical treatment has improved and the modest benefit from surgery may no longer hold. The article concludes by warning “surgeons to stop taking comfort from the relative risks of intervention and historic studies of medical management” and urges them to look at results of future studies involving best medical management. The article is, however, somewhat inconsistent in avoiding the possibility that surgery has improved and perhaps commits the same fault that it urges against by quoting historic results of surgical management and comparing these to hypothetical results of future medical studies.
There are many carotid surgeons, especially in North America and Australia, who have developed logical techniques allowing them to perform carotid endarterectomy with minimal morbidity especially in asymptomatic patients. The Australian and New Zealand Society for Vascular Surgery has recently introduced the compulsory web-based Australasian Vascular Audit (AVA)1. The authors could apply to the audit monitoring committee of the AVA to look at de-identified results showing that many vascular surgeons in Australia and New Zealand operate with zero (or close to it) death and stoke rate in asymptomatic patients.
Surgeons who operate with such low morbidity in asymptomatic patients find it difficult to deny such patients a procedure which they believe is benign, often with just an overnight stay in hospital2. Many of them would have witnessed the devastating consequences of inaction on the part of non surgeons who manage carotid pathology, compounding their conviction.
The authors are correct in calling for studies involving best medical treatment but such studies should include an arm which combines best surgery with best medical treatment.
Bernie Bourke MBBS (Syd) FRACS DDU
Chairman ANZSVS Audit / CPD Committee
References
1. Bourke BM, Beiles B. The Australasian Vascular Audit (AVA) ANZ J Surg. 2010; 80 (Suppl. 1) VS 18 A101
2. Bourke BM, Crimmins DS. Overnight Stay for Carotid Endarterectomy. MJA 1998; 168: 157-162
