Is It Warranted in Asymptomatic Individuals if Risk Factors Are Aggressively Managed?
Asymptomatic Carotid Artery Stenosis
It is estimated that 2% to 12% of adults have >50% stenosis of the carotid arteries. Carotid stenosis is a strong indicator of systemic atherosclerotic disease with subsequent adverse health outcomes including myocardial infarction, stroke, and renal and peripheral arterial disease. The risk of stroke, usually resulting from carotid embolism to the middle cerebral artery or its branches, is low in asymptomatic carotid stenosis but spikes once persons experience ischemic symptoms (ipsilateral transient ischemic attack or stroke). The principal health objective is to prevent conversion to symptomatic stenosis. Even greater public health impact can be achieved with risk factor reduction that attenuates associated myocardial infarction, strokes from noncarotid causes, and peripheral arterial disease. Direct vascular intervention, carotid endarterectomy (CEA), or carotid artery stent/angioplasty (CAS) can reduce stroke risk in persons with symptomatic carotid stenosis, but evidence for their absolute value in improving health for the millions with asymptomatic stenosis is less firm. The Carotid Revascularization using Endarterectomy or Stenting Trial-2 (CREST2) team is embarking on an ambitious clinical …