Management of asymptomatic carotid artery stenosis

No topic in the field of vascular surgery evokes more controversy than the management of the patient with asymptomatic carotid artery stenosis. The fact remains, however, that patients can and do develop stroke without any antecedent TIA, and there is no definite and predictable way to identify the stroke-prone group. Despite considerable differences of opinion in the literature, our evaluation and experience suggest that certain carotid lesions do in fact carry a high risk of stroke without surgical treatment. We continue to recommend prophylactic carotid endarterectomy for selected asymptomatic carotid lesions. A critical review of the published literature reveals that many series which suggest that nonoperative treatment of asymptomatic carotid disease carries a low stroke risk have in fact followed the patients for an inadequate period of time, and frequently do not adequately define the extent of carotid artery disease. It is now clear that studies which use the presence or absence of carotid bruit alone as a marker for subsequent stroke risk, show a relatively low incidence of stroke during brief follow-up periods. If more objective criteria such as non-invasive tests or angiography are used to identify hemodynamically significant stenoses, then the risk of stroke increases with the length of follow-up. The data suggest that high-grade stenoses, particularly preocclusive ones, and deep or compound ulcers have an unfavorable prognosis. The physician who treats patients with asymptomatic carotid stenosis should make every attempt to accurately quantitate the extent of disease. Non-invasive studies, digital subtraction angiography or conventional cerebral arteriography should be performed.(ABSTRACT TRUNCATED AT 250 WORDS)