The Future of Carotid Surgery: Changes and Problems to Solve

With the publication of the results of clinical trials and acceptance of the role of carotid endarterectomy for treatment of carotid bifurcation disease, it will be up to the surgeons to set the standards for performance that are consistent with the expected outcome. This is a complex issue that will have to be addressed and monitored continually to ensure that patients obtain the optimal and expected results. It will be incumbent on the surgical community to not only set the standards but also to set up mechanisms to monitor the performance of surgeons involved in this procedure. From a scientific standpoint, a great deal of work needs to be done to identify those changes in the plaque that are responsible for the production of clinical events. At present, the only finding that is predictive of outcome is the degree of narrowing. Whereas it is the high-grade lesions that lead to events, the majority will remain benign and not lead to cerebral ischemia. To carry out such research it will be necessary to develop three-dimensional imaging methods that permit measurement of the fibrous cap and the materials beneath it. Since plaque cap rupture with embolization, and in some cases, thrombosis, are the primary causes of clinical events, it will be necessary to measure the cap thickness in symptom-free as well as symptomatic patients. Since high-resolution ultrasonography can identify precisely the site of plaque removal, repeat studies of this area will permit its use as a method for documenting the extent and rate of arterial wall healing, and those factors that might protect against the development of myointimal hyperplasia.