Improved outcomes of carotid endarterectomy: the critical role of vascular surgeons.

Improved outcomes after carotid endarterectomy (CEA) have been related to preoperative, intraoperative, and postoperative patient and procedural variables. Outcomes after CEA have also been related to other factors that are not clearly related to the patient or the procedure, such as performance of the procedure in high volume hospitals, by high volume surgeons, and by surgeons specializing in vascular surgery. These overlapping surrogate markers of "quality" have been widely quoted and may be used by external parties to limit access to vascular care; however, these markers have unclear significance when examined systematically. Some of the confounding variables that preclude easy interpretation of these markers include interest of the surgeon in the care of vascular patients, surgical talent, surgical judgment, recognition of patients at higher risk for complications, and routine or selective use of adjunctive medications such as beta-blockers, statins, and anti-platelet agents. The practices of vascular surgeons with excellent outcomes after CEA need to be examined critically for these underlying factors that affect not only procedural results but also long-term stroke-free survival.