Endarterectomy for asymptomatic carotid artery stenosis. Carotid endarterectomy for asymptomatic stenosis jama. Early carotid endarterectomy for symptomatic stenosis of. Carotid artery stenosis, both symptomatic and asymptomatic, has been well studied with several multicenter randomized trials. Efficacy of carotid endarterectomy for asymptomatic carotid. Nice has also produced guidance on carotid artery stent placement for symptomatic extracranial carotid stenosis nice interventional procedure guidance 389, april 2011. Executive committee for the asyl11ptomatic carotid atherosclerosis study. The relative efficacy and safety of carotid endarterectomy cea and carotid stenting cas in patients with asymptomatic carotid stenosis remain unclear. This is being justified on the basis of much higher risks with medical therapy in. This is being justified on the basis of much higher risks with medical therapy in trials conducted decades ago. To determine whether the addition of carotid endarterectomy to aggressive medical management can reduce the incidence of cerebral infarction in patients with asymptomatic carotid artery stenosis. Patients with asymptomatic carotid artery stenosis of 60% or greater reduction in diameter and whose general health makes them good candidates for elective surgery will have a reduced 5year risk of ipsilateral stroke if carotid endarterectomy performed with less than 3% perioperative morbidity and mortality is added to aggressive. To deny screening for asymptomatic carotid stenosis, and to fail to treat it with intensive therapy when it is discovered, do not make physiological sense. This type of surgery is performed to prevent stroke caused by atherosclerotic plaque at the common carotid artery bifurcation and, most important, internal carotid artery.
Pdf time to rethink management strategies in asymptomatic. How to identify which patients with asymptomatic carotid. Carotid endarterectomy for patients with asymptomatic internal carotid artery stenosis. People with asymptomatic carotid stenosis, which is almost always due to atheroma, are seldom asymptomatic. Pdf carotid stenting versus endarterectomy for asymptomatic. Original contributions i endarterectomy for asymptomatic. Nov 20, 2007 asymptomatic severe 50% atherosclerotic stenosis of the proximal internal carotid artery is common in older individuals and is responsible for about 918% of all ischemic strokes in the. Carotidarterystenosis executive committee for the asymptomatic carotid atherosclerosis study objective. View or download all content the institution has subscribed to. With modern intensive medical therapy, the annual risk of ipsilateral stroke in patients with asymptomatic carotid stenosis acs is now down to. Carotid artery stenosis stenting or endarterectomy.
Patients with asymptomatic carotid artery stenosis of 60% or greater reduction in diameter and whose general health makes them good candidates for elective surgery will have a reduced 5year risk of ipsilateral stroke if carotid endarterectomy performed with less than 3% perioperative morbidity and mortality is added to aggressive management. Pdf endarterectomy for asymptomatic carotid artery stenosis. Carotid angioplasty and stenting cas has been proffered as effective and used in treating individuals with asymptomatic carotid stenosis despite the absence of proven clinical equivalency. Reasonable doubt justifies randomisation european and north american clinicians have always differed in their management of carotid artery disease.
Therapeutic options include carotid endarterectomy. Half this reduction is in disabling or fatal strokes. Evidence shows that 94% of all carotid endarterectomy and carotid artery stenting procedures in asymptomatic patients in the us are ultimately. To compare carotid endarterectomy with carotid artery stenting in the prevention of. This randomized trial was designed to explore the hypothesis that cas is equivalent to cea for treating asymptomatic carotid stenosis. Carotid endarterectomy for asymptomatic carotid stenosis is. Management strategies for asymptomatic carotid stenosis. Despite about a 3% perioperative stroke or death rate, cea for asymptomatic carotid stenosis reduces the risk of ipsilateral stroke, and any stroke, by approximately 30% over three years. This study investigates realworld outcomes of cea in asymptomatic octogenarians. Successful cea for asymptomatic patients younger than 75 years of age reduces 10year stroke risks.
Carotid endarterectomy cea to prevent future strokes in asymptomatic carotid stenosis in octogenarians has come under criticism because of the lack of controlled randomized data in this population, the small incremental benefit of treating asymptomatic stenosis, and the more limited life expectancy of octogenarians compared with younger patients. Description the main arteries in the neck the carotid arteries can become narrowed by fatty deposits. So although carotid stenosis may be asymptomatic in the sense that there have been no downstream symptomatic ischaemic events in the brain. Carotid endarterectomy for asymptomatic carotid stenosis in. In the crest trial, which included 2,502 symptomatic and asymptomatic patients with severe carotid artery stenosis, the 10year rate of ipsilateral stroke excluding the periprocedural period was. The superiority of carotid endarterectomy cea to medical therapy alone in both symptomatic and asymptomatic carotid artery stenosis has been well established in previous trials in the 1990s. Endarterectomy, stenting, or neither for asymptomatic carotid. Carotid endarterectomy for asymptomatic carotid stenosis in the very. To examine comparative evidence on management strategies for asymptomatic carotid stenosis and the incidence of ipsilateral stroke with medical therapy alone. Adults with asymptomatic carotid artery stenosis are at increased risk for ipsilateral carotid territory ischemic stroke. Over the last 15 years, carotid artery stenting cas. Endarterectomy for asymptomatic stenosis nejm journal watch.
Carotid endarterectomy for asymptomatic stenosis firming. Efficacy of carotid endarterectomy for asymptomatic carotid stenosis. Angioplasty in asymptomatic carotid artery stenosis vs. Carotid stenosis is a narrowing of a major artery in the neck taking blood to the brain. Appropriate management of asymptomatic carotid stenosis. The goal of this study is to further understand when it is best to operate and when it is best to treat with medications, as this is not always an easy decision. Carotid stenting versus endarterectomy for asymptomatic carotid artery stenosis. Carotid stenting versus endarterectomy for asymptomatic. Editor,we agree with craig d irvine and colleagues general caution about the appropriateness of prophylactic carotid endarterectomy in asymptomatic patients. Both natural history studies, as well as several large, multicenter, randomized controlled studies, have shown that asymptomatic carotid stenosis is quite a benign disease, with an annual stroke rate of only 12% and a strokerelated annual mortality rate of merely 50% carries a 0.
The effect of endarterectomy for asymptomatic carotid stenosis on the risk of any stroke and operative death by sex in acst 17 and acas. Firstly, irvine and colleagues state that 2030% of strokes may be related to carotid disease. From january 1997 to november 2007, there were 387 patients operated on for asymptomatic carotid stenosis. Carotid artery stenting versus carotid endarterectomy for. Existing measures for the effectiveness of endarterectomy among patients with symptomatic carotid disease have been based on the degree of stenosis from strong clinical trial data. Safety of stenting and endarterectomy for asymptomatic. Asymptomatic carotid artery stenosis affects 7% of women and 12% of men, and is especially prevalent among patients aged 70 years. The question of whether patients with asymptomatic carotid stenosis benefit from surgery appears to be resolved. Endarterectomy for asymptomatic carotid artery stenosis the bmj. We elected to include in the present study all patients undergoing carotid endarterectomy cea for symptomatic carotid stenosis scs after an ipsilateral acute within 24 hr tia or ischemic minormoderate stroke if surgical intervention was performed within 48 hr and 14 days after the acute.
Endarterectomy, stenting, or neither for asymptomatic. Carotid endarterectomy cea is the gold standard to prevent a recurrent stroke in symptomatic patients with carotid stenosis. Carotid endarterectomy has been firmly established as the gold standard of therapy for symptomatic and asymptomatic patients with severe carotid stenosis, provided surgical complication rates are within prescribed limits. The question of whether patients with asymptomatic carotid stenosis benefit from surgery appears to be resolved the final results from the asymptomatic carotid atherosclerosis study acas confirm the preliminary findings announced last year these patients do benefit from endarterectomy. Efficacy of carotid endarterectomy for asymptomatic. Thirtynine clinical sites across the united states and canada. Carotid endarterectomy for asymptomatic carotid stenosis. For most people with a narrowing of the carotid artery which is not causing symptoms a surgical operation to remove the narrowing carries a risk and has little benefit.
Role of ct angiographic plaque morphologic characteristics. Jun 16, 2015 the asymptomatic carotid artery study acas was a wellconducted study that assessed carotid endarterectomy cea in asymptomatic carotid artery stenosis 60% for stroke prevention. Important data from two large, randomized trials comparing early and late outcomes after carotid endarterectomy and carotidartery stenting have now been published in the journal. If the narrowing is severe and has caused symptoms, surgery to remove the narrowing carotid endarterectomy reduces the risk of stroke.
What is the future of asymptomatic carotid artery disease. Equally suboptimal, however, is the policy of offering only best medical treatment bmt to all patients with acs and not considering any of them for prophylactic cea. Overview carotid artery stent placement for asymptomatic. Carotid endarterectomy for asymptomatic carotid stenosis stroke. Apr 27, 2011 nice has also produced guidance on carotid artery stent placement for symptomatic extracranial carotid stenosis nice interventional procedure guidance 389, april 2011. Carotid endarterectomy was beneficial with a statistically significant absolute risk reduction of 5. Carotid endarterectomy may be considered for patients between ages 40 to 75 years, with asymptomatic stenosis between 60% to 99%, if there is a 5year life expectancy and surgical risk is asymptomatic patients undergoing carotid endarterectomy should receive aspirin 81 or 325 mg daily prior to surgery and for at least 3. After all, atheroma is generally a widespread disease if it affects one artery it probably affects others.
Since carotid artery atherosclerosis can largely progress silently and unpredictably, the first manifestation can be a debilitating or fatal stroke. Pmc free article hobson rw, 2nd, weiss dg, fields ws, goldstone j, moore ws, towne jb, wright cb. In this article, we present our experience with such operations performed under local anaesthesia. Patients with recently symptomatic carotid artery stenosis were randomly assigned in a 1. Asymptomatic carotid artery stenosis affects approximately 7 percent of women and over 12 percent of men, older than 70 years of age. Offering routine carotid endarterectomy cea or carotid artery stenting cas to patients with asymptomatic carotid artery stenosis acs is no longer considered as the optimal management of these patients. Asymptomatic carotid artery stenosisits time to stop. Crest 2 is an ongoing clinical trial randomizing patients to surgery or medical management of carotid artery stenosis that is asymptomatic has not caused tia or stroke.
Endarterectomy, stenting, or neither for asymptomatic carotid artery stenosis j. Safety of stenting and endarterectomy for asymptomatic carotid. However, in the modern era, the benefit of cea in asymptomatic octogenarian patients has come into question. Endarterectomy for asymptomatic carotid artery stenosis article pdf available in bmj clinical research 31170. Carotid endarterectomy for asymptomatic severe stenosis.
Surgical correction of the kinked carotid artery pdf. Carotid endarterectomy may be considered for patients between ages 40 to 75 years, with asymptomatic stenosis between 60% to 99%, if there is a 5year life expectancy and surgical risk is 50% atherosclerotic stenosis of the proximal internal carotid artery is common in older individuals and is responsible for. Surgical correction of the kinked carotid artery david rosenthal, md, atlanta, georgia paul e. Carotid artery stenting compared with endarterectomy in. Equally suboptimal, however, is the policy of offering only best medical treatment bmt to all patients with acs and not considering any of them for. Carotid endarterectomy for asymptomatic carotid stenosis is safe in. Carotid endarterectomy cea, the mostcommonly used surgical procedure to prevent stroke, has. Important data from two large, randomized trials comparing early and late outcomes after carotid endarterectomy and carotid artery stenting have now been published in the journal. The indication for carotid endarterectomy cea is uncertain in patients with asymptomatic severe. Carotid endarterectomy has been firmly established as the gold standard of therapy for symptomatic and asymptomatic patients with severe carotid stenosis. However, the absolute risk reduction is small approximately 1% per annum over the first few years of follow up in the two largest and most recent trials but it could be higher with. Net benefit in future patients will depend on their risks from unoperated carotid lesions which will be reduced by medication, on future surgical risks which might differ from those in trials, and on whether life expectancy exceeds 10 years.
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