Interventions for carotid artery disease: time to confront some ‘inconvenient truths’

The landmark randomized trials, comparing best medical therapy with carotid endarterectomy, in patients with symptomatic and asymptomatic carotid artery disease set the standard for developing evidence-based practice guidelines throughout the world. Accordingly, the vox populi opinion now tends to be that all otherwise-fit symptomatic patients with 50–90% stenoses (using the NASCET measurement method) and low-risk asymptomatic patients with 60–99% stenoses should be considered for intervention, the only debate being whether the intervention is surgery or angioplasty. Yet, the concept of ‘one size fits all’ is fundamentally flawed and masks a number of ‘inconvenient truths’. Four of these are debated in this review including: the deleterious effect of delaying treatment in symptomatic patients, the fact that there is no ‘gender equality’ in carotid artery disease, the concept of ‘high risk’ has been abused, and ‘low-risk’ registries are no substitute for performing randomized trials.