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To the Editor:
In the special article on consent issues in the management of cerebrovascular diseases,1 the authors put the cart before the horse by emphasizing the tradeoff between immediate risk and long-term benefit. They note that for carotid endarterectomy, accurate local data on morbidity and mortality for the surgical and medical options are essential components of the adequate-information component of informed consent. They neglect evidence that this information is usually not available2-4 and is difficult to empirically ascertain,3 and do not mention that there is evidence suggesting little or no benefit in many locales.3-5 The following discussion concentrates on endarterectomy for high-grade symptomatic stenosis.
The benefit demonstrated in NASCET6 is based (among other caveats) on a 2.1% major complication (major stroke or death) rate with benefits diminishing until they disappear at a rate of 10%.6 In clinical practice, many surgeons are performing endarterectomies with unacceptable complication rates. From 1992 to 1993, the perioperative …
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