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Asymptomatic carotid disease: changing perspectives
1Tulane University School of Medicine.
Insights
Recent findings clarify carotid stenosis risks, indicating bruits pose low stroke risk. Severe stenosis (>70%) has a 3% annual stroke risk, and prophylactic surgery for asymptomatic carotid stenosis shows no proven benefit.
Area of Science:
- Neurology
- Vascular Surgery
- Public Health
Background:
- Recent data have improved understanding of carotid stenosis risks and stroke etiology.
- Cervical bruits are associated with a minimal stroke risk.
- Severe carotid stenosis (>70%) is uncommon in the general population, conferring a 3% annual stroke risk.
Purpose of the Study:
- To review the current understanding of carotid stenosis and stroke risk.
- To evaluate the efficacy and safety of surgical intervention for asymptomatic carotid stenosis.
Main Methods:
- Literature review of studies published in the last decade.
- Analysis of stroke risk associated with carotid stenosis severity.
- Assessment of surgical outcomes and risks for carotid endarterectomy.
Main Results:
- Only 15% of strokes are attributable to surgically accessible carotid disease.
- Prophylactic carotid endarterectomy has not demonstrated significant benefit.
- Surgery for asymptomatic carotid stenosis carries an acceptable risk of no more than 3%.
Conclusions:
- The optimal management strategy for carotid stenosis remains undetermined.
- Surgery for asymptomatic carotid stenosis must achieve very low risk to be beneficial.
- Current evidence does not support surgical intervention improving the natural history of asymptomatic carotid stenosis.
Abstract:
Information acquired in the last decade has clarified the risk of carotid stenosis and defined multiple causes of stroke. Bruits are associated with very low risk of stroke. Severe stenosis (> 70%) is rare in the general population and only implies a 3%/year stroke risk. Strokes have many causes with as few as 15% due to surgically accessible carotid disease. Studies to date have shown no benefit to prophylactic endarterectomy. Patients with carotid stenosis undergoing surgery have also been shown to be at no significant increased risk. The acceptable risk for surgery on asymptomatic disease is no more than 3%. Whether this can be achieved in the community is unclear. The ideal management of carotid stenosis is unclear. Surgery for asymptomatic disease must be very low risk to be beneficial and, to date, has not been shown to improve the natural history of the problem.