Abstract
Cervical carotid artery stenosis is amenable to correction by surgical endarterectomy or by endovascular angioplasty and stenting, with low rates of peri-procedural complications. Yet in asymptomatic patients treated medically, rates of stroke associated with medically-treated carotid stenosis are low, limiting the potential benefits of these interventions. Randomized prospective trials including the Asymptomatic Carotid Atherosclerosis Study (ACAS), the Veterans Affairs (VA) study, and the Asymptomatic Carotid Surgery Trial 1 (ACST-1), all demonstrated some benefit of endarterectomy over medical therapy for asymptomatic stenosis. However there is uncertainty whether the benefit persists with respect to modern medical therapy, which has advanced since the time of these trials. For carotid angioplasty and stenting for asymptomatic carotid stenosis, benefits can only be indirectly inferred, based on results found to be comparable to those with endarterectomy in prospective trials. Based on current evidence, medical therapy, including control of risk factors, antiplatelet and statin therapy, and blood pressure treatment, are recommended for all patients with atherosclerotic carotid plaque. Endarterectomy for asymptomatic carotid stenosis can be recommended conditionally, in patients with severe stenosis. Carotid angioplasty and stenting for asymptomatic patients can only be recommended in selected cases where patient factors preclude safe endarterectomy. Stratification of risk based on plaque characteristics or detection of microemboli from asymptomatic carotid plaque may contribute to decision making in favor of intervention over medical management. Comparison of endarterectomy or angioplasty and stenting to modern medical therapy in a randomized, prospective fashion, such as is proposed in the CREST-2 trial, is needed to provide better guidance in these management decisions.
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Brorson, J.R. (2017). In Patients with Asymptomatic Carotid Artery Stenosis Does Current Best Medical Management Reduce the Risk of Stroke Compared to Intervention (Endarterectomy or Stent)?. In: Skelly, C., Milner, R. (eds) Difficult Decisions in Vascular Surgery. Difficult Decisions in Surgery: An Evidence-Based Approach. Springer, Cham. https://doi.org/10.1007/978-3-319-33293-2_26
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DOI: https://doi.org/10.1007/978-3-319-33293-2_26
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