Carotid Stenosis – Medicine or Surgery?

Atherosclerosis of the carotid arteries is a common precursor to stroke. It produces narrowing of the artery lumen, with the occurrence of a carotid bruit or recognizable plaques on ultrasound examination. It doesn’t usually produce symptoms until a stroke or a mini-stroke – a transient ischemic attack or TIA – occurs. However, one-half to two-thirds of the patients who have surgery to remove the partial blockage (carotid endarterectomy with or without a stent) don’t have any symptoms.

Is this surgery necessary, or could the narrowing be treated with drugs? A Canadian specialist has presented study data at the World Stroke Congress in Vienna showing that intensive medical treatment is an alternative, or even a better option.

A special ultrasound exam (transcranial Doppler) can detect microemboli (minute clots) in the brain that predict strokes. In 2003 the intensity of medication to prevent stroke were increased in the Western Ontario study. Before the intensification, 12.6% of the patients had microemboli – after, only 3.7%. Taking these findings, the principal investigator says: “The 96% of patients without microemboli have only a 1% risk of stroke in the next year, whereas the ones with microemboli have a 14% risk . . . Since the risk of surgery is 4% to 5%, patients without microemboli are better off with medical therapy including medications and lifestyle modifications. Only the ones with microemboli would benefit from carotid embolectomy or stenting.”

These findings, if confirmed in another study, strongly suggest that revascularization surgery is unnecessary for 95% of patients with carotid stenosis without symptoms. Something HMOs will cheer, and vascular surgeons will lament.