Fighting Windmills With Asymptomatic Carotid Stenosis

Abstract

Abbott et al. 1 claim that they wish to "alert readers to factual errors and omissions" in our recently published review. 2 They support that the "high-risk criteria" defined by the 2017 European Society for Vascular Surgery guidelines 3 as imaging/clinical characteristics that may be associated with an increased risk for late ipsilateral stroke in patients with asymptomatic carotid stenosis (AsxCS) have not been tested in randomized controlled trials (RCTs). However, the authors should know that it is not possible to have an RCT to answer every single clinical problem in medicine. Furthermore, as clinicians it is inappropriate to tell AsxCS patients that since no RCT has addressed their specific condition, we cannot address their concerns about the optimal management of their AsxCS. The management of AsxCS patients' needs to be individualized taking into consideration among others, individual patient preferences, needs and expectations, carotid plaque features/characteristics, imaging criteria, as well as the recommendations of the current guidelines. 4 Abbott et al. claim that the average annual ipsilateral stroke rates in AsxCS patients approximate only .8% with nonprocedural management. 1 Such low average annual ipsilateral stroke rates may be possible in patients with moderate AsxCS. It is of interest that an earlier prospective international cohort study (where Dr. Abbott is a co-author), the Asymptomatic Carotid Stenosis and Risk of Stroke (ACSRS) study including 1121 AsxCS patients followed up for a mean 4 years demonstrated that the average annual ipsilateral stroke rates in AsxCS actually varied from 0% to 3.1%. 5 Furthermore, a recent single-center study of a large academic institution in Southeastern United States reported a 2-year incidence of cerebrovascular events (stroke and transient ischemic attack [TIA]) as high as 11.5%. 6 Although it can be argued that the quality of medically intervention received by the AsxCS patients in this study was incompletely documented or that it did not address all risk factors, this pragmatic report suggests that ipsilateral annual TIA and stroke rates in patients with >70% AsxCS are not as low in "real-life" conditions as supported by Abbott et al. 1 Finally, a 2021 population-based cohort study (Oxford Vascular Study) and a systematic review

Best Medical Treatment Alone Is Adequate for the Management of All Patients With Asymptomatic Carotid Stenosis, or “Alice in Wonderland”

“…16 Claiming that BMT alone is adequate for all AsxCS patients is not currently supported by any RCT evidence. 17,18 As physicians, it is our duty to ensure that each patient receives optimal care according to individual needs, expectations, age, and comorbidities. 19 Although all AsxCS patients should receive counseling, risk factor management and optimal medical therapy, BMT alone is not adequate for many of them.…”

“…19 Although all AsxCS patients should receive counseling, risk factor management and optimal medical therapy, BMT alone is not adequate for many of them. [12][13][14]17,18 Having "Alice-in-Wonderland" vision of reality and expecting that all patients will be constantly and fully adherent with the advice provided by their vascular surgeons/ physicians can have fatal consequences for patients.…”

“…19 Although all AsxCS patients should receive counseling, risk factor management and optimal medical therapy, BMT alone is not adequate for many of them. 12-14,17,18…”