Asymptomatic carotid artery stenosis: Time to rethink our therapeutic options?

Neurosurgical FOCUS (Impact Factor: 2.11). 01/2014; 36(1):E2. DOI: 10.3171/2013.10.FOCUS13389
Source: PubMed


Asymptomatic carotid artery stenosis is a well-recognized risk factor for ischemic stroke, and its prevalence increases with age. In the late 1980s and in the 1990s, well-designed randomized trials established a definite advantage for carotid endarterectomy in reducing the risk of ipsilateral stroke when compared with medical therapy alone. However, medical treatment of cardiovascular disease has improved significantly over the past 2 decades, and this has, in turn, resulted in a decline of the stroke risk in patients with asymptomatic carotid artery stenosis treated medically. This improvement in medical therapy casts doubts on the effectiveness of large-scale invasive treatment in patients with asymptomatic carotid artery stenosis. Several studies have been conducted to identify possible subgroups of patients with asymptomatic stenosis who are at higher risk of stroke in order to maximize the potential benefits of invasive treatment. Ongoing large-scale trials comparing best current medical therapy to available invasive treatments, such as carotid endarterectomy and carotid artery stenting, are likely to shed some light on this debated topic in the near future. In this review, the authors summarize the current controversy surrounding the ideal management of asymptomatic carotid artery stenosis.

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    ABSTRACT: Asymptomatic carotid stenosis (ACS) has a high prevalence and a small possibility of stroke. Its treatment involves the application of the so-called, intensive medical treatment (IMT) of the arteriosclerosis, and in selected cases, carotid surgery, either by endarterectomy (TEA) or a Stent (CAS). The current indications are based on old clinical trials in which the current medical treatment was not applied, and the only selection criterion relating to the lesion was the grade of stenosis. With the application of IMT, the stroke rate in patients with ACS is currently similar to that obtained in the surgical arm of the clinical trials, results that are better than in normal practice. If there is a sub-group of patients who could benefit from surgery, then they are those with an unstable plaque despite the IMT. For all this, we should be cautious when performing a surgical intervention in patients with ACS. Randomised clinical trials are needed to compare CAS, TEA, and the improved medical treatment in patients with ACS.
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    ABSTRACT: Background and purpose: Minorities and uninsured/underinsured patients have poorer access to healthcare system resources, especially preventative treatments. We sought to determine whether racial and insurance based disparities existed in the treatment of carotid artery stenosis. Methods: Using the Nationwide Inpatient Sample, hospitalizations for carotid artery stenting and carotid endarterectomy for symptomatic and asymptomatic carotid artery stenosis from 2005 to 2011 were identified. We calculated χ(2) tests, and bivariate and multivariable logistic regression models were fit to assess differences in the characteristics of patients receiving carotid revascularization for asymptomatic compared with symptomatic carotid artery stenosis. Demographic characteristics studied included race/ethnicity (white, black, Hispanic, Asian/Pacific Islander) and primary payer status (Medicare, Medicaid, private insurance, self-pay and no charge). Results: Between 2005 and 2011, 890 680 patients underwent carotid revascularization for the treatment of carotid artery stenosis (92.1% asymptomatic and 7.9% symptomatic). Multivariate logistic regression analysis demonstrated that Medicaid (OR=0.87, 95% CI 0.83 to 0.92, p<0.0001) and self-pay patients (OR=0.48, 95% CI 0.45 to 0.51, p<0.0001) had a lower odds of being revascularized for asymptomatic carotid artery stenosis compared with private insurance patients. Black (OR=0.81, 95% CI -0.77 to 0.84, p<0.0001) and Hispanic (OR=0.86, 95% CI -0.83 to 0.90, p<0.0001) patients had significantly lower odds of revascularization for asymptomatic carotid artery stenosis compared with white patients. Conclusions: Minorities and self-pay/Medicaid patients were less likely to receive carotid revascularization when asymptomatic-rather they were more likely to have treatment only after symptoms had developed. These findings suggest possible disparities in the degree of morbidity related to carotid artery stenosis, the likelihood of early detection, and/or the likelihood of treatment conditional on indication.
    Journal of Neurointerventional Surgery 07/2014; 7(9). DOI:10.1136/neurintsurg-2014-011294 · 2.77 Impact Factor
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    ABSTRACT: In this review, we presented the evidence concerning carotid artery stenosis treatment in symptomatic stenosis and asymptomatic stenosis separately, and discussed the future challenges. The validity of carotid endarterectomy (CEA) to treat moderate or greater degree of symptomatic carotid artery stenosis appears to be established. Due to the additional option of carotid artery stenting (CAS), it is necessary to comprehensively determine whether CEA or CAS is more appropriate for each individual patient. Moreover, since there are rapid advancements in devices for CAS and improvements in treatment outcomes, continual learning of the latest treatment method is essential. For asymptomatic stenosis, due to improvements in the outcomes with best medical treatment (BMT), it is essential to re-evaluate the use of invasive CEA/CAS. Continual verification of the latest randomized clinical trial that compares CEA, CAS, and BMT, and establishment of a diagnostic method that can accurately extract the group of patients who have the highest future risk of developing ischemia, are desired.
    Neurologia medico-chirurgica 02/2015; 55(3). DOI:10.2176/nmc.ra.2014-0361 · 0.72 Impact Factor