The urgent need for contemporary clinical trials in patients with asymptomatic carotid stenosis

Abstract

Asymptomatic extracranial internal carotid artery atherosclerotic stenosis increases with age and is more common in men. Studies performed more than 2 decades ago showed that carotid endarterectomy reduced the rate of stroke in carefully selected patients with asymptomatic carotid stenosis compared with medical therapy in the long term. Those trials were completed more than 20 years ago and with advances in the treatment of atherosclerotic disease, the question has been raised to as to whether endarterectomy is still of value for patients with asymptomatic narrowing. Perioperative risk of carotid revascularization procedures has also declined. Due to improvements in both medical and surgical treatments for carotid artery stenosis, it is timely to reevaluate the efficacy of carotid intervention relative to medical treatment for patients with asymptomatic stenosis.

Circulating inflammation-resolving lipid mediators RvD1 and DHA are decreased in patients with acutely symptomatic carotid disease

“…The stroke reduction benefit from CEA over medical therapy in patients with asymptomatic carotid disease is based on randomized controlled trials from the 1990s[32]. Since that time, however, both the safety of surgery (CEA) and medical management of carotid disease have improved[33]. Many now question which is the best therapy for the patient with asymptomatic high-grade carotid disease[33].…”

“…Since that time, however, both the safety of surgery (CEA) and medical management of carotid disease have improved[33]. Many now question which is the best therapy for the patient with asymptomatic high-grade carotid disease[33]. Identification of circulating inflammation-resolving lipid mediators could, hypothetically, be used to predict which individuals with high-grade asymptomatic carotid disease are at risk of plaque rupture and stroke.…”

Optimal Medical Management Reduces Risk of Disease Progression and Ischemic Events in Asymptomatic Carotid Stenosis Patients: A Long-Term Follow-Up Study

“…Though there is a recent downward trend, a majority of CRV in the United States are still performed for asymptomatic carotid artery disease [12,13]. The CREST-2 study is designed to compare the outcomes in ACAS patients randomized to optimal medical management or CRV but it is still an ongoing study [14]. Several recent publications have suggested that the risk of IS/transient ischemic attack (TIA) in ACAS patients has decreased significantly in recent years.…”

Metabolic and Molecular Imaging of Atherosclerosis and Venous Thromboembolism

“…Therefore, we anticipate that future studies of carotid 18 F-FDG PET will extend the initial insights provided by Marnane et al (6), and better determine which carotid lesions are high risk and warrant a more intensive medical or interventional approach. This is an area of vital importance, as there remains controversy about when to intervene on asymptomatic severe interval carotid artery lesions, and whether biologic data (beyond currently available stenosis information) might help guide that decision (36). Risk-benefit of radiation exposure and costeffectiveness will need to be further analyzed.…”