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

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.