Effect of Contralateral Occlusion on Long-Term Efficacy of Endarterectomy in the Asymptomatic Carotid Atherosclerosis Study (ACAS)

Abstract

for the ACAS InvestigatorsBackground and Purpose-The Asymptomatic Carotid Atherosclerosis Study (ACAS) established the effectiveness of prophylactic carotid endarterectomy, for patients in good health who had stenosis Ն60%, if conducted by surgeons with a surgical morbidity and mortality of Ͻ3%. This secondary analysis was performed to determine whether the presence of contralateral cervical carotid occlusion alters the efficacy of asymptomatic ipsilateral carotid endarterectomy. Methods-One hundred sixty-three participants who had a baseline contralateral occlusion documented by Doppler ultrasound (77 medical, 86 surgical) were compared with 1485 participants with a patent contralateral carotid artery (748 medical, 737 surgical) for the risk of a combined end point of perioperative (30-day) death or stroke or long-term (5-year) ipsilateral stroke. Results-For those without contralateral occlusion, surgery was associated with a 6.7% absolute reduction in the 5-year risk (95% CI, 2.1% to 11.4%), while for those with a contralateral occlusion, surgery was associated with a 2.0% absolute increase in risk (95% CI, Ϫ9.3% to 5.2%), which was a statistically significant difference in the effect of surgery (Pϭ0.047). This difference is primarily attributable to low long-term risk for medically managed patients with contralateral occlusion. Conclusions-While this post hoc analysis should be interpreted with caution, the findings suggest that endarterectomy in asymptomatic subjects with contralateral occlusion provides no long-term benefit (and may be harmful) in preventing stroke and death. These findings were a result of the benign course of medically treated subjects. (Stroke.

Carotid endarterectomy—An evidence-based review [RETIRED]

“…17 Conversely, for patients with asymptomatic stenosis, if there is a contralateral occlusion, the only randomized evidence suggests that patients do slightly better with medical management (2.0% absolute increase in risk with CE at 5 years). 18 For patients with angiographic near-occlusion, the pooled analysis of the symptomatic studies suggests that CE is associated with a trend toward benefit at 2 years but no clear benefit at 5 years (1.7% trend favoring medical treatment at 5 years). 8 It should be recognized that BMT patients in NASCET with severe stenosis, including those with near-occlusion, were offered CE after the 2-year results were made available.…”

Realizing the Potential of Carotid Artery Stenting

“…38,44 Owing to the very low event rates in patients with asymptomatic lesions of moderate severity (Ͻ60% diameter stenosis), it is unknown whether currently available interventional techniques can improve long-term outcomes over those achievable with optimal medical management. Also unresolved are the indications for carotid stenting in asymptomatic individuals with contralateral carotid occlusion 48 and those undergoing major cardiac or vascular surgery. 49 …”

Carotid Endarterectomy with Routine Shunt for Patients with Contralateral Carotid Occlusion

“…CEA has been confirmed as a durable procedure for carotid stenosis by many prospective randomized control trials (RCTs), such as NASCET, ECST, etc. 1,2,10) The presence of CCO has been traditionally regarded as a risk factor for perioperative complications after CEA. 11) NASCET reported that the patients with CCO had a significantly higher incidence of 30-day complications.…”