The Best Treatment for Carotid Artery Narrowing?

Stenosis, or narrowing, of the carotid arteries is usually caused by an atherosclerotic plaque in the blood vessel.  It’s diagnosed by a stethoscope detecting a gurgling or rushing noise in the artery, or by ultrasound of the artery.  Detection is important, because this is one of the major causes of ischemic stroke.    

Carotid stenosis may or may not cause symptoms.  Detection of carotid atherosclerosis should lead to efforts to slow, stop, or reverse the atherosclerotic process, using diet, exercise, and cholesterol-lowering medications.  If more than a given percentage of the lumen of the artery is lost, ‘intervention’ is advisable.  This usually involves surgery to remove the atherosclerotic plaques, but more recently less-invasive angioplasty or stent placement has been used.

In the last few years, studies have been done comparing the outcomes of endarterectomy and stenting.  Their results have not been very consistent, but the view is emerging that stenting is less safe, both in the short- and long-term analyses.  Stroke and death rates are higher, and there’s the likelihood that, with stenting, changes in the brain occur that may lead to vascular dementia.          

To complicate matters, recent evidence has surfaced that carotid narrowing without symptoms can be treated with medical therapy, including anticoagulation and lipid lowering, and that this is more successful in reducing the rate of stroke than endarterectomy (or a stent).  No prospective, randomized trials have been reported that show this, but they are planned. 

Clearly the best treatment is not a clear-cut matter.  The procedures involved in surgery (endarterectomy or angioplasty with or without a stent) are very expensive, compared with medical treatment;  it would be a blow to manufacturers of specialized surgical instrumentation if medical treatment proved to be superior. Interestingly, in the USA 70% of surgical procedures for stenosis are done on asymptomatic patients, compared with 5% in the UK.  Of course, this may be partially due to differing rates of diagnosis in the two countries . . . 

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