Invited commentary

Abstract

There has been recent renewed scrutiny into the appropriateness of performing prophylactic interventions on patients with severe asymptomatic carotid artery atherosclerotic plaque to prevent future strokes. Prophylactic carotid endarterectomy (CEA) has been demonstrated in several randomized, prospective trials to provide superior stroke prevention compared with contemporaneous medical therapies in patients with severe carotid artery stenosis. However, ongoing current discussions have focused on the premise that the incidence of ischemic stroke may be decreasing and the hypothesis that improved pharmacologic therapies, such as statin medications, may be responsible for the decreasing stroke rate. If one were a proponent of these hypotheses, it would be natural to conclude that the risk-benefit balance with regard to surgical treatment of asymptomatic severe carotid artery atherosclerosis might have indeed tipped toward the medical therapy side of the seesaw. Nevertheless, stroke remains the fourth leading cause of death in the United States and the leading cause of long-term disability and institutionalization. Stroke represents a major worldwide patient and economic burden. The treatment of stroke, once it has occurred, is generally unsuccessful. Clearly, all physicians would be eager for improved tools to designate those patients at highest risk for stroke as well as for enriched stroke-prevention strategies and methods. With regard to prophylactic carotid endarterectomy (CEA) in asymptomatic patients, knowledge about the patient's long-term survival is critical to properly evaluate whether a patient will derive potential benefit from prophylactic surgical intervention. In this regard, the current study from the Vascular Study Group of New England provides important data for the clinician who evaluates patients with carotid artery disease. A large cohort of asymptomatic patients who underwent CEA was evaluated, and the perioperative stroke and mortality rates were extremely low. More than 80% of the patients who underwent CEA achieved 5-year survival after their surgery. On the basis of randomized, prospective data, this should theoretically be long enough to attain stroke-prevention benefit in appropriately selected asymptomatic patients. A patient should probably not be considered for prophylactic CEA if his or her individual life expectancy is felt to be <3 years. However, 5% of the patient cohort was deemed to be at “high risk” for early death because of comorbid conditions; only 51% of patients in this category would be expected to achieve 5-year survival. In addition, 68% of patients who underwent CEA were deemed “moderate risk,” and only 80% of the patients in this category would be expected to achieve 5-year survival. Clearly, there is room for improvement in patient selection in this regard. The major risk factors for early mortality included advanced age ≥80 years (hazard ratio, 3.94) and dialysis-dependent renal failure (hazard ratio, 3.41); these are not unexpected findings. Unfortunately, the current report is somewhat less successful in discriminating the relative contribution of more “minor” risk factors for death, including congestive heart failure, chronic obstructive pulmonary disease, insulin-dependent diabetes, and the degree of contralateral carotid artery stenosis. Most patients who are evaluated for asymptomatic carotid artery disease will be aged <80 years and not in dialysis-dependent failure; most will also likely have at least one “minor” risk for early mortality, placing them in the “moderate-risk” category according to the risk stratification system derived by the authors. Nevertheless, the current data do provide a valid framework for clinicians to contemplate when choosing appropriate asymptomatic patients for CEA. In addition to considering the degree of stenosis, other anatomic and morphologic characteristics, and the individual patient's risk of perioperative complications after surgery, it is critical for the surgeon to weigh the patient's long-term survival in order to achieve an appropriate stroke-prevention benefit. Certainly, patients deemed at “high risk” for early mortality should probably not be considered for prophylactic CEA, and patients at “moderate risk” need to be carefully considered. Optimal selection of asymptomatic patients for carotid endarterectomy based on predicted 5-year survivalJournal of Vascular SurgeryVol. 58Issue 1PreviewAlthough carotid endarterectomy (CEA) is performed to prevent stroke, long-term survival is essential to ensure benefit, especially in asymptomatic patients. We examined factors associated with 5-year survival following CEA in patients with asymptomatic internal carotid artery (ICA) stenosis. Full-Text PDF Open Archive