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Asymptomatic carotid artery stenosis—it's time to stop operating

Nature Clinical Practice Neurology volume 4, pages 4–5 (2008)Cite this article

Asymptomatic severe (>50%) atherosclerotic stenosis of the proximal internal carotid artery is common in older individuals and is responsible for about 9–18% of all ischemic strokes in the anterior circulation.1 It is, therefore, important to determine how best to prevent stroke caused by this lesion. Most clinicians are likely to advise management of vascular disease risk factors for patients with asymptomatic severe carotid artery stenosis (CAS) because many of these patients are identified through symptoms of atherosclerosis. The role of additional surgery (carotid endarterectomy [CEA]) has been controversial. I believe, however, that a surgical approach to stroke prevention in these patients is not warranted, for reasons discussed in this Viewpoint.

In some countries, surgery on asymptomatic severe CAS is common.1 Recommendations to perform surgery (or stenting) for asymptomatic patients have been made largely on the basis of a small overall stroke-prevention benefit of about 1% per year2 with CEA (combined with medical intervention) seen in three randomized trials conducted during the period 1983–2004.3,4,5 The surgical stroke-prevention benefit in the two larger trials, ACAS and ACST, was estimated to begin about 1–2 years after surgery, becoming significant by 3–5 years.4,5 No data on long-term outcomes are available. Recommendations to perform surgery have usually come with the caveat that the perioperative risk of stroke or death at the operating center should be less than 3% (the average risk observed in the randomized trials).1

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  1. National Stroke Research Institute, Austin Health, Level 1, Neurosciences Building, 300 Waterdale Road, Heidelberg Heights, Victoria 3081, Australia a.abbott@nsri.org.au

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  1. A Abbott is an Honorary Senior Research Fellow at the National Stroke Research Institute in Melbourne, Victoria, Australia.,

    Anne Abbott

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Abbott, A. Asymptomatic carotid artery stenosis—it's time to stop operating. Nat Rev Neurol 4, 4–5 (2008). https://doi.org/10.1038/ncpneuro0682

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