Asymptomatic Carotid Stenosis: Mainly a Medical Condition

At present approximately 70% of carotid endarterectomy and stenting in the United States is being performed for asymptomatic carotid stenosis (ACS). This is based on historical risks of ACS that no longer pertain in the era of intensive medical therapy with statins and other therapies. In the past, the surgical risk of 3% in clinical trials was marginally better than medical therapy for male patients with ACS; however, this is no longer the case. Even in the past, women with ACS did not benefit from endarterectomy. Except for patients with microemboli on transcranial Doppler (who have a 2-year risk of stroke of approximately 14%), the 2-year risk of stroke in ACS is now 1% or less. Endarterectomy or stenting should be reserved for the < 5% of patients with microemboli on transcranial Doppler ultrasonography. In future, 3 dimensional ultrasound detection of ulceration, and magnetic resonance imaging of vulnerable plaque may provide additional approaches to identifying those patients with ACS who may benefit from endarterectomy or stenting. Routine endarterectomy or stenting for patients with ACS should now be regarded as inappropriate.