We thank Dr Buskens for his comments. The question of whom not to offer a surgical procedure or lifesaving medical treatment is certainly a crucial debate. The debaters include physicians, those in legal professions, ethicists, economists, actuaries, politicians, and special interest groups among others.
From a strictly medical perspective, we agree there are patient subsets for whom carotid endarterectomy (CEA) is not likely to have a meaningful positive effect on quality or duration of life. Patients of any age with significant comorbidities (smoking, coronary artery disease, severe diabetes, cancer) have shown decreased longevity at 5 years by about 50%. As LaMuraglia et al1 recently argued, “The problem is to be able to conclusively identify which risk factors or comorbidities are of major significance in these carotid patients and how long they may survive.”