Asymptomatic severe carotid stenosis

The management of asymptomatic carotid stenosis remains controversial. From December 1983 to December 1987, 188 symptom-free patients were found to have severe (greater than 75%) stenosis by duplex imaging (performed as screening examination). Patients with non-hemispheric symptoms or contralateral symptomatic lesions (within 7 years) were excluded from the study. Follow-up data were available for 141 patients (range 3 to 36 months; mean 21 months). Sixty-two patients received nonoperative therapy. The remaining 79 patients underwent 100 carotid endarterectomies (CAE) (21 staged bilateral repairs and 58 unilateral repairs). There were no statistically significant differences in sex, age, or risk factors (i.e., hypertension, diabetes, or smoking) or in the incidence of bilateral disease. Significant differences were found in the incidence of ischemic attacks (0 vs 21%; p less than 0.001) and stroke (2.5% vs 18%; p less than 0.01) in the operative vs nonoperative group. None of the 11 strokes in the nonoperative group were preceded by neurologic events. The operative group had an overall stroke rate of 2.5% (2/79), a perioperative mortality rate of 1.3% (1/79), and a restenosis (greater than 50%) rate of 3.8% (3/79). Thus favorable results can be achieved with prophylactic CAE. These data support the use of prophylactic CAE in any patient with greater than 75% stenosis identified by duplex image, regardless of sex, age, risk factors, or bilateral disease.