Commentary

It is certainly clear that most patients with symptoms and >70% carotid stenosis are better off with surgical than medical treatment. However, the data remain murky for asymptomatic patients, even with publication of the excellent ACST by Halliday et al.¹

CEA is a nettlesome issue for internists, in part because the benefits of preventive “roto rooter” arterial cleaning seem obvious to many patients with carotid stenosis discovered in the course of a physical examination with subsequent testing. Before concluding that most asymptomatic patients with ⩾60% diameter reduction on carotid ultrasonography should be referred to vascular surgeons, I would suggest that the following patient care protocols merit serious and open minded attention.

Firstly, because it is critically important in decision making to know if the carotid lesion is truly asymptomatic, I would suggest that such patients be referred in the first instance to an experienced neurologist, rather than a surgeon. Secondly, because the experience of technologists performing ultrasonography varies widely, computed tomographic angiography or magnetic resonance angiography should confirm the stenosis before surgery is considered. Thirdly, patients must recognize that they face only a 2% annual stroke rate with medical care, and that surgical morbidity and mortality is 3% among the most experienced surgeons. Fourthly, the surgical experience and track record of the surgeon to whom a patient is referred should be readily available, because operative complications may exceed the low rates of optimum care in research centres by 1% to 2%.

Finally, some evidence (albeit anecdotal) suggests that the process of insidious carotid stenosis can be arrested and perhaps reversed by scrupulous control of risk factors. The jury is still out, but progression of carotid stenosis over time may be preventable, provided that the patient is strongly motivated and the doctor has excellent communication skills.²