Informed consent: What level of risk to disclose with carotid artery endarterectomy?

You are asked to see a 65-year-old man with an asymptomatic high-grade carotid artery stenosis. He is otherwise quite healthy, is receiving appropriate medical management, and has no contraindications for surgery. You recommend a carotid endarterectomy (CEA) as the best prophylactic measure against stroke. During the informed consent process, the patient asks for a specific estimate of the risks. What specific level of risk should you quote to your patient? AMention the Asymptomatic Carotid Surgery Trial (ACST)¹ and the Asymptomatic Carotid Arteriosclerosis Study (ACAS)² as the "best case scenario" so as not to discourage the patient from undergoing this operation.BYou don't like to be pinned down by numbers, so you tell your patient that the risk is "small."CAs a result of a recent quality assurance audit, you are aware that your stroke and death rate after CEA in asymptomatic patients is 7%. You recognize that this is high, but quote this risk to your patient as the "expected local results."DYou're aware that the American Heart Association recommends CEA for high-grade stenoses if the perioperative risk of stroke or death is <3%.^3,4 As a result of your 7% rate, you rethink the utility of CEA in asymptomatic patients in your hands and refer to him to a colleague.