Abstract-Significant advances in vascular disease medical intervention since large randomized trials for asymptomatic severe carotid stenosis were conducted have prompted doubt over current expectations of a surgical benefit. In this systematic review and analysis of published data it was found that rates of ipsilateral and any-territory stroke (ϩ/ϪTIA), with medical intervention alone, have fallen significantly since the mid-1980s, with recent estimates overlapping those of operated patients in randomized trials. However, current medical intervention alone was estimated at least 3 to 8 times more cost-effective. In conclusion, current vascular disease medical intervention alone is now best for stroke prevention associated with asymptomatic severe carotid stenosis given this new evidence, other cardiovascular benefits, and because high-risk patients who benefit from additional carotid surgery or angioplasty/stenting cannot be identified. (Stroke. 2009;40:e573-e583.)Key Words: asymptomatic carotid stenosis Ⅲ carotid endarterectomy Ⅲ endovascular treatment Ⅲ health policy Ⅲ stroke preventionThe best intervention is prevention and the best prevention is noninvasive.A symptomatic severe carotid stenosis generally means atherosclerotic narrowing of the proximal internal carotid artery (ICA) exceeding Ϸ50% to 60% in the absence of previous referrable symptoms of stroke or transient ischemic attack (TIA). This lesion, at least in Westernized communities, becomes increasingly prevalent from the fifth decade, affecting Ϸ10% of those aged over 80 years. 1 It accounts for Ϸ12% to 21% of all anterior circulation ischemic strokes, 1 Ϸ2 to 3 times higher than the risk for less severe asymptomatic stenosis. 2,3 In many countries surgery (or carotid endarterectomy [CEA]) for asymptomatic severe carotid stenosis is supported by best practice guidelines 4 -6 and commonly recommended 7 or performed 8,9 to prevent stroke. This is largely because of the results of 3 major randomized surgical trials: the Veterans' Affairs Cooperative Study (VACS), 10 the Asymptomatic Carotid Atherosclerosis Study (ACAS), 11 and the Asymptomatic Carotid Surgery Trial (ACST) 12 conducted 1983 to 2003.Despite differing primary outcome measures, there was an overall reduction of Ϸ1% in average annual absolute stroke risk among patients who received CEA plus medical intervention. 13 However, for decades this expensive approach has been questioned because the estimated surgical benefit was marginal and highly dependent on patient selection, nature of the medical and surgical interventions used, and reporting methods. 1 Further, nonoperated patients with higher than average stroke risk who particularly benefit from CEA cannot be identified. 14 Now carotid angioplasty/stenting, with higher procedural costs 15 and similar major complication rates (at least for symptomatic patients 16 ) is being proposed as the best prophylactic intervention 17 without even randomized trial evidence of efficacy.Vascular disease medical intervention is the combination ...

The purpose of this study was to determine the cerebrovascular risk stratification potential of baseline degree of stenosis, clinical features, and ultrasonic plaque characteristics in patients with asymptomatic internal carotid artery (ICA) stenosis

Background and Purpose-We systematically compared and appraised contemporary guidelines on management of asymptomatic and symptomatic carotid artery stenosis. Methods-We systematically searched for guideline recommendations on carotid endarterectomy (CEA) or carotid angioplasty/stenting (CAS) published in any language between January 1, 2008, and January 28, 2015. Only the latest guideline per writing group was selected. Each guideline was analyzed independently by 2 to 6 authors to determine clinical scenarios covered, recommendations given, and scientific evidence used. Results-Thirty-four eligible guidelines were identified from 23 different regions/countries in 6 languages. Of 28 guidelines with asymptomatic carotid artery stenosis procedural recommendations, 24 (86%) endorsed CEA (recommended it should or may be provided) for ≈50% to 99% average-surgical-risk asymptomatic carotid artery stenosis, 17 (61%) endorsed CAS, 8 (29%) opposed CAS, and 1 (4%) endorsed medical treatment alone. For asymptomatic carotid artery stenosis patients considered high-CEA-risk because of comorbidities, vascular anatomy, or undefined reasons, CAS was endorsed in 13 guidelines (46%). Thirty-one of 33 guidelines (94%) with symptomatic carotid artery stenosis procedural recommendations endorsed CEA for patients with ≈50% to 99% average-CEA-risk symptomatic carotid artery stenosis, 19 (58%) endorsed CAS and 9 (27%) opposed CAS. For high-CEA-risk symptomatic carotid artery stenosis because of comorbidities, vascular anatomy, or undefined reasons, CAS was endorsed in 27 guidelines (82%). Guideline procedural recommendations were based only on results of trials in which patients were randomized 12 to 34 years ago, rarely reflected medical treatment improvements and often understated potential CAS hazards. Qualifying terminology summarizing recommendations or evidence lacked standardization, impeding guideline interpretation, and comparison. This systematic review of contemporary international guidelines was performed to compare and appraise recommendations for the management of patients with ACS and SCS (including accessibility, organization, clarity, and consistency) and the evidence used in making these recommendations. Conclusions-This Methods Guideline SearchesGuidelines with recommendations on the use of CEA or CAS or both patients with ACS or SCS or both were sought systematically using popular search engines, bibliographies, and author professional networks. PubMed and ISI Web of Knowledge were searched independently and synchronously by 2 authors on September 9, 2013 (A.L.A., K.I.P.). PubMed was searched using carotid guideline and then stroke guideline in the title, yielding 91 references after duplicate removal. ISI Web of Knowledge was searched using carotid and guideline and then stroke and guideline in the title, yielding 422 references after removal of duplicates, abstracts, reference materials, letters, corrections, meetings, news, and case reports. Wider searches using the words carotid or stroke and guideline in any ...