[Surgical indications in asymptomatic internal carotid artery stenosis and in relation to heart surgery interventions]

Abstract

In the last 30 years, carotid endarterectomy has been employed on a wide-spread basis with the intention of providing surgical prophylaxis of stroke. Currently, however, there is no evidence available from prospective, randomized comparative studies indicating a clear superiority of surgical treatment versus medical treatment with respect to stroke prophylaxis or improvement in survival. Based on recent publications with sufficiently large patient populations, operative mortality appears to be about 1% and the rate of perioperative stroke about 3.4%. In those with symptomatic internal carotid stenosis, without surgery there is a 5% yearly risk of cerebral infarction such that carotid endarterectomy possibly appears warranted. In contrast, in association with asymptomatic internal carotid stenosis, that is, in the absence of any symptoms indicative of cerebral hypoperfusion, based on several recent prospective studies, the yearly rate of cerebral infarction is 1 to 2% and, consequently, less than that of the prophylactic surgical intervention. Additionally, carotid endarterectomy does not render complete protection against stroke and the follow-up curves for the respective treatments do not differ meaningfully, even during longterm observation. Accordingly, for asymptomatic internal carotid stenosis, the indication for surgery has not been clearly established. Among those with asymptomatic carotid stenosis, there may be a subgroup of individuals with high-grade luminal obstruction or multiple vessel disease, who according to several studies, appear to be at a higher risk of subsequent complications even though this has not yet been confirmed by prospective, randomized studies.(ABSTRACT TRUNCATED AT 250 WORDS)