Asymptomatic carotid disease

Abstract

The advent of noninvasive screening tests has allowed the identification of an increasing number of patients with asymptomatic carotid stenoses. The management of these patients must be individualized, as the preferred method of therapy has not been established. Such a solution ultimately requires a prospective randomized trial to define the natural history of these lesions and to clearly establish if surgical therapy has a role. Currently, there is a Veterans Administration Cooperative Study underway which will attempt to fill the existing information gap. Specifically being examined is the relationship between subsequent cerebrovascular symptoms and the degree of stenosis, progression of stenosis, contralateral disease and non-carotid operation. This study will not be completed for five years, so that other, current guidelines must be sought. It is essential that any surgeon considering prophylactic carotid endarterectomy demonstrate combined morbidity and mortality figures of less than 3 per cent. The patients being considered must also be an acceptable cardiac risk, as myocardial infarction represents the most common postoperative complication. Until prospective data is available, with a detailed analysis of the degree of stenosis, presence of ulceration and ultimate clinical course, the surgeon undertaking prophylactic endarterectomy must carefully screen his patients and concentrate on groups at high risk. This is especially important as more data on the significant incidence (10 to 15 per cent) of carotid restenosis becomes available. The results of three studies (34, 36, 69) suggest that those patients with hemodynamically significant stenoses, identified noninvasively by OPG techniques, are at a greater risk for cerebral ischemic events than those patients without significant stenoses. In addition, an observed incidence of stroke of 17.5 per cent and an indicence of TIAs of 33 per cent in patients with disease progression demonstrated by OPG-K/CPA. The work of another researcher (71) suggests that patients with carotid stenoses can be observed until symptoms develop or until the stenosis progresses to greater than 80 per cent.(ABSTRACT TRUNCATED AT 400 WORDS)