Carotid endarterectomy in patients with intraluminal thrombus.

In response to the extraordinary increase in the number of carotid endarterectomies performed in this country, there is a rising wave of skepticism about the value of and the indications for this procedure. Conventional wisdom has held that one of the strongest indications for urgent carotid endarterectomy is the finding that a patient with ipsilateral ischemic symptoms has an intraluminal thrombus associated with an atherosclerotic plaque at the carotid bifurcation. An important article in this issue of Stroke by Buchan and colleagues from the University of Western Ontario describes the relatively poor results obtained at that institution with endarterectomy based on these conditions. In contrast, another group of patients under similar circumstances treated initially with anticoagulant drugs fared better. On the basis of their experience Buchan et al recommend deferring surgery and treating these patients with anticoagulants, at least initially. Because this recommendation is contrary to a widely accepted therapeutic approach, it should not go unchallenged.