WHAT THIS PAPER ADDSIn this single institution retrospective analysis of patients with asymptomatic internal carotid artery stenosis identified on duplex ultrasound as moderate to severe (70%e80%) from 2003 to 2018. There was a low rate (5.3%) of stroke/transient ischaemic attack without documented progression of stenosis, but there was a high rate (24.1%) of stenosis progression, as well as a 16.3% mortality rate at five years. The data reinforce the need to follow these patients closely, and patients at a higher risk of death, in particular, may benefit the least from intervention.Objective: Treatment of asymptomatic internal carotid artery (ICA) stenosis, particularly for moderate to severe (70%e80%) disease, is controversial. The goal was to assess the clinical course of patients with moderate to severe carotid stenosis. Methods: A single institution retrospective analysis of patients with asymptomatic ICA stenosis identified on duplex ultrasound as moderate to severe (70%e80%) from 2003 to 2018 were analysed. Duplex criteria for 70%e80% stenosis was a systolic velocity of !325 cm/s or an ICA:common carotid artery ratio of !4, and an end diastolic velocity of <140 cm/s. Asymptomatic status was defined as no stroke/transient ischaemic attack (TIA) within six months of index duplex. Primary outcomes were progression of stenosis to >80%, ipsilateral stroke/TIA without documented progression, and death. Results: In total, 206 carotid arteries were identified in 182 patients meeting the inclusion criteria. Mean patient age was 71.5 years, 57.7% were male, and 67% were white. There were 19 stenoses removed from analysis except for survival analysis as they initially underwent carotid endarterectomy or carotid artery stent based on surgeon/patient preference. Documented progression occurred in 24.1% of stenoses. There were 5.3% of stenoses associated with an ipsilateral stroke/TIA without documented progression, which occurred at a mean of 26.4 months. KaplaneMeier analysis demonstrated a 60.3% five year freedom from stenosis progression, 92.5% five year freedom from stroke/TIA without documented progression, and 83.7% five year survival. Risk factors associated with stroke/TIA without documented progression at five years were atrial fibrillation (hazard ratio [HR] 14.87, 95% confidence interval [CI] 2.72e81.16; p ¼ .002) and clopidogrel use at index duplex (HR 6.19, 95% CI 1.33e28.83; p ¼ .020). Risk factors associated with death at five years were end stage renal disease (HR 9.67, 95% CI 2.05e45.6; p ¼ .004), atrial fibrillation (HR 7.55, 95% CI 2.48e23; p < .001), prior head/neck radiation (HR 6.37, 95% CI 1.39e29.31; p ¼ .017), non-obese patients (HR 5.49, 95% CI 1.52e20; p ¼ .009), and non-aspirin use at index duplex (HR 3.05, 95% CI 1.12e8.33; p ¼ .030). Conclusion: Patients with asymptomatic moderate to severe carotid stenosis had a low rate of stroke/TIA without documented progression. However, there was a high rate of stenosis progression reinforcing the need to follow these patients closely.

did not change across the different age groups. The rates of in-hospital stroke/death after TCAR were 1.4% in patients 70 years or younger vs1.9% in those 71 to 79 years and 1.5% in those 80 years and older (P ¼ .55). A comparison of TCAR with CEA across different age groups showed no significant differences in outcomes, and no interaction was noted between treatment and age (Table ). When compared with TFCAS, no differences were noted between TCAR and TFCAS in patients less than 80 years of age. However, in patients 80 years and older, TCAR was associated with a 72% reduction in stroke risk (4.7% vs 1.0%,; odds ratio [OR], 0.28; 95% confidence interval [CI], 0.12-0.65; P < .01), a 65% reduction in risk of stroke/death (4.6% vs 1.5%; OR, 0.35; 95% CI, 0.20-0.62; P < .001), and 76% reduction in the risk of stroke/death/myocardial infarction (5.3% vs 2.5%; OR, 0.24; 95% CI, 0.12-0.47; P < .001) compared with TFCAS.