For severe carotid stenosis found on ultrasound, further arterial evaluation prior to carotid endarterectomy is unnecessary: the argument against.

Abstract

Carotid endarterectomy reduces the risk of stroke in certain patients with recently symptomatic carotid stenosis1 and to a lesser extent inpatients with severe asymptomatic stenosis.2 Screening of patients for inclusion in the randomized controlled trials (RCTs) was usually performed with Doppler ultrasound (DU), but conventional arterial angiography (CAA) was required prior to randomization in the RCTs in symptomatic stenosis1 and prior to surgery in ACAS.2 However, CAA is costly, time-consuming, and can cause stroke. A systematic review of prospective studies of the risks of CAA inpatients with cerebrovascular disease reported a 0.1% risk of death and a 1.0% risk of permanent neurological sequelae.3 More recent studies have reported lower risks in both academic centers and community hospitals,4 but many centers have already adopted a policy of operating on the basis of DU alone.5 The main advantage of DU over CAA is the absence of a procedural risk. However, it should be noted that most studies of the risk of CAA classified all strokes that occurred within 24 hours of CAA as procedural complications. Given that the risk of stroke shortly after presentation with symptomatic carotid stenosis and …