Medical Management and Revascularization for Asymptomatic Carotid Stenosis

Area of Science:

• Neurology
• Vascular Surgery
• Clinical Trials

Background:

• Advances in medical therapy, carotid stenting, and endarterectomy necessitate re-evaluation of asymptomatic carotid stenosis management.
• The comparative benefit of revascularization plus intensive medical management versus medical management alone remains unclear.

Purpose of the Study:

• To compare the efficacy of carotid artery stenting plus intensive medical management versus intensive medical management alone for high-grade asymptomatic carotid stenosis.
• To compare the efficacy of carotid endarterectomy plus intensive medical management versus intensive medical management alone for high-grade asymptomatic carotid stenosis.

Main Methods:

• Two parallel, observer-blinded clinical trials enrolled patients with high-grade (≥70%) asymptomatic carotid stenosis across 155 centers.
• The primary outcome was a composite of stroke or death within 44 days, or ipsilateral ischemic stroke up to 4 years.

Main Results:

• In the stenting trial, the 4-year event rate was 2.8% for stenting plus medical management vs. 6.0% for medical management alone (P=0.02).
• In the endarterectomy trial, the 4-year event rate was 3.7% for endarterectomy plus medical management vs. 5.3% for medical management alone (P=0.24).
• Perioperative stroke/death rates were higher in the stenting and endarterectomy groups compared to the medical-therapy group within 44 days.

Conclusions:

• Carotid artery stenting, when added to intensive medical management, significantly reduced the risk of stroke or death in patients with high-grade asymptomatic carotid stenosis.
• Carotid endarterectomy did not demonstrate a significant benefit over intensive medical management alone in this patient population.