Controversies in the management of carotid stenosis

Controversies surround the indications for and methods of diagnosis of carotid stenosis. Carotid endarterectomy is of proven value for patients presenting with transient ischemic attacks or minor stroke and angiographic atherosclerotic carotid stenosis of greater than 70% if endarterectomy can be carried out with a surgical morbidity and mortality of less than 6%. It is generally not indicated for stenosis less than 30%. For intermediate levels of stenosis, studies to determine its efficacy are ongoing. Endarterectomy can also decrease the risk of stroke in asymptomatic patients, although indications in asymptomatic patients remain controversial. Conventional angiography remains the gold standard for diagnosis of carotid stenosis. Improvements in ultrasound technology and magnetic resonance angiography have led some surgeons to rely only on these tests preoperatively rather than perform conventional angiography. It would be advantageous to be able to avoid the 1% risk of angiography but further study is indicated before this approach can be accepted. Carotid angioplasty remains an investigational procedure.