Abstract
Purpose of ReviewProvide a current overview regarding the optimal strategy for managing patients with asymptomatic carotid artery stenosis.Recent FindingsCarotid endarterectomy (CEA) and carotid artery stenting (CAS) reduce long-term stroke risk in asymptomatic patients. However, CAS is associated with a higher risk of peri-procedural stroke. Improvements in best medical therapy (BMT) have renewed uncertainty regarding the extent to which results from older randomised controlled trials (RCTs) comparing outcomes following carotid intervention can be generalised to modern medical practise.Summary‘Average surgical risk’ patients with an asymptomatic carotid artery stenosis of 60–99% and increased risk of late stroke should be considered for either CEA or CAS. In patients deemed ‘high risk’ for surgery, CAS is indicated. Use of an anti-platelet, anti-hypertensive and statin, with strict glycaemic control, is recommended. Results from ongoing large, multicentre RCTs comparing CEA, CAS and BMT will provide clarity regarding the optimal management of patients with asymptomatic carotid artery stenosis.
Highlights
Thromboembolic stroke is a major cause of morbidity and mortality in the United Kingdom (UK)
In diabetic patients with asymptomatic carotid artery stenosis, tight glycaemic control is recommended as these patients are at increased risk of stroke [49]
A subgroup analysis of the recently completed Cardiovascular Outcomes for People using Anticoagulation Strategies (COMPASS) randomised clinical trial (RCT) showed that addition of low-dose rivaroxaban to aspirin reduced the overall major adverse cardiovascular event rate (HR 0.63 (0.38–1.05; p = 0.07) [64]
Summary
Thromboembolic stroke is a major cause of morbidity and mortality in the United Kingdom (UK). In the United States of America (USA) alone, strokes are the third most common cause of death, with atherosclerotic stenosis of the carotid artery implicated in 20–25% of all strokes [3]. Stenosis of the carotid artery has been reported to place an individual at more than 3% increased risk of having a stroke in the year (a greater than 50% increased relative risk) [4]. Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are effective long-term stroke prevention strategies in symptomatic patients. This review article outlines the techniques of carotid intervention, presents the evidence for and against the use of CEA and CAS in stroke prevention in asymptomatic patients, summarises the role of BMT and highlights the current research focus in this important subject
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