Is there a role for revascularisation in asymptomatic carotid stenosis? No

BMJ 2010; 341 doi: http://dx.doi.org/10.1136/bmj.c4900 (Published 15 September 2010)
Cite this as: BMJ 2010;341:c4900

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  1. J David Spence, director
  1. 1Stroke Prevention andAtherosclerosis Research Centre, Robarts Research Institute, University of Western Ontario, 1400 Western Road, London, ON, Canada N6G 2V2
  1. dspence{at}robarts.ca

    Marco Roffi (doi:10.1136/bmj.c4898) thinks revascularisation should be the strategy of choice for patients with asymptomatic carotid stenosis but J David Spence argues that all but a tiny minority would do better with medical management

    Carotid endarterectomy and stenting for asymptomatic stenosis are based on historical risks that no longer pertain. With more intensive medical management (including lifestyle modification), the risk of stroke or death is now lower than with intervention; patients with asymptomatic stenosis are now more likely to be harmed than helped. In most cases, carotid stenting or endarterectomy for asymptomatic stenosis is inappropriate and unwarranted.

    In the Asymptomatic Carotid Artery Surgery and Asymptomatic Carotid Surgery randomised trials, the extrapolated five year risk of stroke or death was about 10% with medical management versus about 5% with surgery.1 2 Those outdated figures are now being compared with recent results of the Carotid Revascularisation Endarterectomy versus Stenting Trial (CREST),3 to justify routine endarterectomy or stenting. In CREST, patients with carotid stenosis were randomised to endarterectomy or stenting; 47% of participants had asymptomatic stenosis. The periprocedural risk of stroke was 2.5% for stenting and 1.4% for endarterectomy (with four year risks of 4.5% …

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