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My name is Brian Hoh,
and I'm the James and Bridgette Marino Family Professor
and Chair of Neurosurgery in the Lillian S. Wells
Department of Neurosurgery at the University of Florida.
This chapter is on prevention,
carotid endarterectomy, angioplasty, and stenting.
I have no disclosures.
I have no commercial interests,
and there will be no discussion of non-FDA-approved for off-label devices or drugs.
Every year, nearly 800,000 people in the United States suffer a stroke.
Stroke is the third leading cause of mortality and
the leading cause of disability in the United States.
On average, every 40 seconds,
someone in the United States has a stroke,
and back in 2010,
the direct and indirect costs of stroke were over $143 billion,
factoring in inflation and the escalation of costs,
this is likely much higher today in 2019.
20 percent of strokes are due to carotid stenosis.
There were three prospective randomized clinical trials that
studied carotid endarterectomy for symptomatic carotid stenosis,
Nascet, the European Carotid Surgery Trial,
and the Veteran Affairs trial.
In this chapter, we will discuss the NASCET trial.
The North American Symptomatic Carotid Endarterectomy Trial studied
the beneficial effects of carotid endarterectomy in
symptomatic patients with high-grade carotid stenosis.
In this trial, 659 patients with greater than 70 percent symptomatic carotid stenosis
among 50 sites in North America were randomized
to optimal medical care versus carotid endarterectomy.
Life table-estimates of cumulative risk of
ipsilateral stroke at two years were determined,
and in the medical arm,
there was a 26 percent risk of stroke at two years
compared to nine percent at two years with carotid endarterectomy.
A statistically significant finding with a p-value of less than 0.001.