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Effective, but not for every patient

By Amos Esty

Carotid endarterectomy is a common surgery to try to prevent a stroke, but many patients undergo the procedure despite being poor candidates for it.

A recent study by Geisel and Dartmouth-Hitchcock researchers found that about 20% of patients who undergo a carotid endarterectomy may be poor candidates for the surgery.

Carotid endarterectomy is an effective treatment for the accumulation of plaque in the arteries that lead to the brain, which can cause a stroke. But because of the risks of the surgery, the Society for Vascular Surgery advises that patients should only be considered for the procedure if their life expectancy exceeds three years.

Jessica Wallaert, M.D., a resident in vascular surgery at Dartmouth-Hitchcock, knew all this. What she wanted to find out was how closely surgeons follow those guidelines.

Wallaert used data from a national database to examine 12,631 carotid endarterectomies performed from 2007 to 2009 at 186 medical centers. Of those cases, 2,525 (20%) involved patients whose overall health made them poor candidates for surgery. These patients had at least one life-limiting condition, such as cancer, liver disease, congestive heart failure, or chronic obstructive pulmonary disease. After surgery, these patients were almost three times more likely than healthier patients to have a stroke or die.

"This is a striking finding," Wallaert says.

She conducted the study as a Veterans Affairs National Quality Scholar during a research fellowship taken as part of her surgery residency. She earned a master's degree at the Dartmouth Institute for Health Policy and Clinical Practice, which she says "inspired me to start being more thoughtful about defining appropriate indications for the surgeries we perform on a daily basis."

There are a few reasons for the prevalence of surgeries in poor candidates, she says. Doctors know that carotid endarterectomy is an effective procedure. Furthermore, even a surgeon who is well aware of the statistics can have difficulty declining to perform a surgery. "Every individual patient is different," Wallaert says. "No study is generalizable to every person, and thus there is a lot of room in surgical decision-making for 'an exception.'"

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Geisel School of Medicine at DartmouthDartmouth-Hitchcock Medical CenterWhite River Junction VAMCNorris Cotton Cancer CenterDartmouth College