Management of Patients with an Asymptomatic Carotid Stenosis--Medical Management, Endovascular Treatment, or Carotid Endarterectomy?

Patients with asymptomatic carotid stenosis all warrant intensive medical therapy; they are at a higher risk of myocardial infarction than of stroke. With modern intensive medical therapy, the annual risk of ipsilateral is now ∼ 0.5%. Justifying carotid intervention on the basis of the results of historic trials with a medical arm, extrapolated to modern trials with lower interventional risks but no medical arm is not legitimate. Most patients (∼ 90%) with asymptomatic carotid stenosis would be better served by intensive medical therapy than by either stenting or endarterectomy. The few (∼ 10%) who could benefit from intervention can be identified by microemboli on transcranial Doppler and other methods in development. Routine stenting of asymptomatic carotid stenosis, because it is more likely to harm than help the patient, may be considered unethical.