Asymptomatic carotid artery stenosis: time to rethink our therapeutic options?

Abstract

<jats:p>Asymptomatic carotid artery stenosis is a well-recognized risk factor for ischemic stroke, and its prevalence increases with age. In the late 1980s and in the 1990s, well-designed randomized trials established a definite advantage for carotid endarterectomy in reducing the risk of ipsilateral stroke when compared with medical therapy alone. However, medical treatment of cardiovascular disease has improved significantly over the past 2 decades, and this has, in turn, resulted in a decline of the stroke risk in patients with asymptomatic carotid artery stenosis treated medically. This improvement in medical therapy casts doubts on the effectiveness of large-scale invasive treatment in patients with asymptomatic carotid artery stenosis. Several studies have been conducted to identify possible subgroups of patients with asymptomatic stenosis who are at higher risk of stroke in order to maximize the potential benefits of invasive treatment. Ongoing large-scale trials comparing best current medical therapy to available invasive treatments, such as carotid endarterectomy and carotid artery stenting, are likely to shed some light on this debated topic in the near future. In this review, the authors summarize the current controversy surrounding the ideal management of asymptomatic carotid artery stenosis.</jats:p>

Racial and insurance based disparities in the treatment of carotid artery stenosis: a study of the Nationwide Inpatient Sample

“…First, the underlying assumption of our study was that patients presenting with symptomatic disease would be treated regardless of symptomatic status. This is likely due to the fact that the advantage of surgery over medical therapy is largest among patients with symptomatic disease 10 11 14. Thus a higher proportion of patients presenting with symptomatic disease will be treated surgically, regardless of insurance status or ability to pay.…”

“…Medical therapy has significantly improved since the publication of the Asymptomatic Carotid Atherosclerosis Study (ACAS) trial which has led many experts to re-evaluate the role of medical therapy in the treatment of asymptomatic carotid artery stenosis 14. In fact, improvement in medical therapy has led many to question the relative benefits of surgical revascularization of patients with asymptomatic carotid artery stenosis.…”

Comparative outcomes of carotid artery stenting for asymptomatic and symptomatic carotid artery stenosis: a single-center prospective study

“…There is currently no unified opinion on whether patients with ACS need to undergo revascularization. One study estimated a 1–3% risk of ipsilateral stroke in patients with ACS 3. In a long-term study, the 10- and 15-year risks of ipsilateral stroke were 5.7% and 8.7% in patients with 0–49% degree of ACS and 9.3% and 16.6% in patients with 50–99% degree of ACS, respectively 4.…”

Endovascular Treatment of Carotid Atherosclerosis: Concerns and Perspectives

“…В последние годы достигнуты значительные успехи в области разработки медикаментозных методов профилактики ишемического инсульта у пациентов с ате-росклерозом магистральных артерий головы, включая новые методы антиагрегантной и гиполипидемиче-ской терапии. Однако их эффективность, по данным на-блюдательных исследований, у больных высокого рис-ка остается недостаточной [9,10]. Учитывая также вы-сокий риск повторного инсульта, составляющий от 2 до 5% в течение года при бессимптомном течении атеро-склероза и до 12% после перенесенного ОНМК, ста-новится несомненной актуальность хирургических ме-тодов лечения церебрального атеросклероза [11][12][13].…”