Diagnosis of Carotid Artery Disease

Carotid endarterectomy (CEA) for prevention of ischemic stroke has been performed since the early 1950s (see Plate 9-16), but it was only in the 1990s that several large-scale trials were performed comparing this type of surgery against best medical treatment in patients with asymptomatic and symptomatic internal carotid artery stenosis.

For patients with asymptomatic internal carotid artery stenosis from 60% to 99%, evidence from the Asymptomatic Carotid Atherosclerosis Study (ACAS) and Asymptomatic Carotid Surgery Trial (ACST) showed a modest benefit favoring CEA, with an absolute stroke risk reduction at 5 years of 5.9% and 5.4%, respectively. The stroke risk reduction was more prominent in men and independent of the degree of stenosis or contralateral disease. Therefore it was concluded that CEA should be considered for patients with asymptomatic stenosis of 60% to 99% if the patients have a life expectancy of at least 5 years and the rate of perioperative stroke or death for the institution or particular surgeon can be reliably kept to less than 3%. Since then, further studies have shown that more intensive medical treatment can decrease the ipsilateral stroke risk to less than 1%. It is possible that the absolute benefit from carotid endarterectomy is even smaller than reported by the above trials. A subgroup of patients with asymptomatic carotid artery disease and microembolism on transcranial Doppler monitoring or imaging markers of a vulnerable plaque or reduced cerebral blood flow reactivity may potentially benefit from vascular intervention; however, further studies will be required to answer this question.

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