Asymptomatic Carotid Stenosis Revascularization: Not for all but Selected Few

Submit Manuscript | http://medcraveonline.com (ACST) demonstrated a positive statistically significant difference when CEA was utilized, however the absolute risk reduction for cerebrovascular events was rather modest compared to the best medical therapy [2,3]. The high number of CEAs required to prevent one ipsilateral stroke in combination with recent advances in best medical therapy, has questioned the surgery in asymptomatic patients in providing best clinical practice [4]. With modern intensive medical therapy, the annual risk of ipsilateral stroke in patients with asymptomatic carotid stenosis is now down to ≤1% per year [5]. For asymptomatic patients, the risk of ipsilateral stroke after CEA is 0.5% per year, but this rate may not be significantly lower than that currently associated with medical therapy alone [1]. When we consider perioperative risks with carotid revascularization procedures in asymptomatic patients, including both carotid endarterectomy and carotid angioplasty and stent placement in major trials including ACAS, ACST, Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST) and The Asymptomatic Carotid Surgery Trial-1 (ACT1), the risk of stroke and death within 30 days ranges from 1.4 % to 3%. Although procedures have become safer over time due to a technological advancement, they are not able to keep up with the efficacy of best medical treatment to a similar extent. We believe that the accepted threshold of 3% for perioperative complication rates during recanalization procedures may indeed be high given the recent advances in best medical treatment.