Does the geometry of the carotid bifurcation affect its predisposition to atheroma?

evaluation of the literature we are not taking a cavalier attitude towards this operation. The exact opposite is true. We are attempting to face the known facts. The important issue, of course, is to ensure that the real risks of this surgery are identified. There is no virtue in attempting to smite an imaginary dragon. It is obvious that the hemodynamic risks in carotid endarterectomy have been greatly exaggerated in the literature. Old assumptions need to be re-evaluated, rather than to be accepted on faith. The key to success appears to relate most to patient selection and surgical skill. It is not advocated, however, that anyone discard a practice in which they feel confident. Although in theory a few patients who are at significant hemodynamic risk might benefit from the use of a shunt, they can not yet be accurately identified. There are potential problems with the use of a shunt, and as a result the net benefit from it's use has yet to be convincingly demonstrated. The purpose of the Editorial was to prompt discussion (which it appears to have done) in the hope that this might help resolve the controversies regarding the safest method of performing this surgery. Time will tell if the viewpoint of the Editorial is correct. Gary G. Ferguson, M.D., F.R.C.S.(C) University of Western Ontario London, Ontario, Canada