Response to Letters by Reiff et al and Hadjiev and Mineva
We greatly appreciate the comments of Reiff and colleagues’ regarding our recent article concerning the management of asymptomatic carotid stenosis.1 As noted in our article, we agree that there is ample evidence that demonstrates that medical management of atherosclerotic disease has improved significantly since Asymptomatic Carotid Atherosclerosis Study (ACAS) and Asymptomatic Carotid Surgery Trial (ACST) were performed. Seventy percent to 80% of carotid interventions in the United States are performed for asymptomatic disease, which may provide the patient with minimal or no benefit over medical management. We could not agree more that there is a desperate need for a contemporary, prospective, randomized study that compares intervention whether it be carotid endarterectomy, carotid angioplasty, and stenting, or both, like in Stent-Protected Angioplasty in Asymptomatic Carotid Artery Stenosis (SPACE-2),2 to best medical management for asymptomatic carotid artery stenosis. We sincerely apologize for being unaware of the SPACE-2 trial and we thank the authors for bringing this important trial to our attention. We look forward to learning the results of the SPACE-2 trial with great anticipation.
We thank Drs Hadjiev and Mineva for their thoughtful comments. We admit to the limitations of our study as we pointed out in the article in that certain important variables are not included in the National Surgical Quality Improvement Program database and therefore limit full characterization of the patient cohort. Although we believe these modern results of carotid endarterectomy for asymptomatic carotid disease are excellent, we are impressed with the results of best medical management as discussed in our article and as pointed out by Drs Hadjiev and Mineva in their letter.
We continue to believe that a prospective, randomized trial of best medical management versus carotid endarterectomy is justified, particularly because the Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST) trial (results recently published) included so many asymptomatic patients and might be interpreted as justification for intervention (endarterectomy versus stent) when best medical management may be more appropriate. We recognize the problems associated with such a trial in that it may hard to justify the cost and recruit the approximately 3000 patients to show a difference when the event rate is low.