To the Editor.— The conclusions and recommendations for patient selection for carotid endarterectomy advanced by Matchar and Pauker1cannot be accepted because they ignore the most important fact: carotid endarterectomy has never been shown to be of any value for any patient under any circumstances. The authors admit that the only randomized controlled trial of endarterectomy failed to show a benefit,2yet they use this 20-year-old study to estimate the efficacy of the procedure in modern patients. There is mounting evidence, such as that from the large, prospective, randomized controlled trial of extracranial-intracranial bypass,3that surgical revascularization is of no benefit in preventing stroke. Whether carotid endarterectomy is also of no benefit is unknown, but there is no scientific evidence of its effectiveness. The relative risks of this procedure in different types of patients are irrelevant when there are no clear benefits. I appreciate the authors' attempt