Management of carotid stenosis

Published on December 31, 2017   21 min
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I'm David Spence. I'm a Professor of Neurology and Clinical Pharmacology at the University of Western Ontario, in London, Canada; And Director of the Stroke Prevention and Atherosclerosis Research Centre at the Robarts Research Institute. This talk is about Management of Carotid Stenosis.
Here are my disclosures, none of which is relevant to this talk.
So, the benefit of carotid endarterectomy was first shown by the North American Symptomatic Carotid Endarterectomy Trial, the NASCET trial, run at our institute, the Robarts Research Institute by my boss, Dr Henry Barnett, and the Asymptomatic Carotid Artery Surgery trial run at Winston-Salem, by Jim Toole. That's ancient history; the first NASCET paper came out in the New England Journal for severe stenosis in 1991, and the moderate stenosis paper came out in 1998, ACAS came out in 1995, so that's a long time ago. However, the NASCET trials showed very clearly, that for patients with symptomatic severe stenosis, there was a huge benefit of endarterectomy; And the number needed to treat to prevent one stroke in two years, in patients with symptomatic stenosis, aged below 75, was 6, the number needed to treat for those aged 75 and older was only 3, and for moderate stenosis it was 15. However, in asymptomatic carotid stenosis, even in the bad old days of ACAS, the risk of stroke was so low that the number needed to treat was approximately 70 or 80 patients who would have to undergo surgery in order to prevent 1 stroke in 2 years. Those risks were predicated on a 3% surgical risk, and historical medical therapy that was much less intensive than what we use now. So, it was clear from NASCET that patients with severe symptomatic carotid stenosis should have medical therapy and endarterectomy, and in selected cases, stenting might be appropriate. So, patients with a high carotid bifurcation making surgery more difficult, patients with previous irradiation and scarring, patients with previous surgery and scarring, patients with a high medical risk, and younger patients, might be suitable for stenting. What about asymptomatic stenosis?