Carotid lesions--to operate or not to operate?

Ischemic cerebrovascular disease, a major public health problem, is accompanied, and possibly caused in a large percentage of cases, by extracranial arterial lesions. A rapidly expanding body of surgical litera­ ture records the success of procedures designed to re­ pair these lesions along with a decline in recent years in surgical mortality for such procedures. If an area of carotid abnormality is a constant threat to adequate cerebral blood flow, why not remove it? There is no fully documented analysis of replies to this important question, but the present view addresses five areas of study that may result in a postponement or rejection of the decision to operate. These areas are not mutually exclusive; rather, they are variables that interact and should be considered in conjunction.