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Is there a role for revascularisation in asymptomatic carotid stenosis? Yes

BMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c4898 (Published 15 September 2010) Cite this as: BMJ 2010;341:c4898
  1. Marco Roffi, director
  1. 1Interventional Cardiology Unit, Division of Cardiology, University Hospital, Rue Micheli-du-Crest 24, 1211 Geneva, Switzerland
  1. Marco.Roffi{at}hcuge.ch

    Marco Roffi thinks revascularisation should be the strategy of choice for patients with asymptomatic carotid stenosis but J David Spence (doi:10.1136/bmj.c4900) argues that all but a tiny minority would do better with medical management

    Large scale randomised trials have shown the benefit of carotid endarterectomy over medical management in patients with >60% asymptomatic stenosis of the internal carotid artery. Nevertheless, the value of revascularisation has been questioned because of the small reduction in absolute risk (about 1% a year) associated with surgery and the lack of best medical treatment in the control arms of the trials. However, the assumption that drug treatment alone may be sufficient to prevent ipsilateral strokes is hazardous and not supported by randomised data. To estimate the benefit of revascularisation the following factors need to be taken into account: the annual risk of (ipsilateral) stroke in asymptomatic patients treated conservatively and the periprocedural and long term risk of stroke after carotid revascularisation.

    Stroke risk in asymptomatic patients

    Although the risk of ispilateral stroke in patients with asymptomatic stenosis is commonly estimated at 1% a year, several studies have identified higher risk subgroups of patients. A trial randomising symptomatic patients to carotid endarterectomy or drug treatment …

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