Q) When should we consider revascularization for patients with asymptomatic carotid stenosis?
A) At this moment in time, we are still waiting for the evidence on whether revascularization in this group of patients is beneficial. CREST-2 trial is ongoing https://www.crest2trial.org/. This trial compares 3 different methods: best medical treatment (BMT), carotid endarterectomy (CEA) and carotid stent (CAS).
European guideline (2017) recommends carotid revascularization in patients with 60-99% stenosis with life expectancy >5 years and have at least one feature suggesting higher stroke risk on BMT (figure 4 and table 4). In “average surgical risk” patients, CEA should be considered (Class IIa, level B) and in “high risk for CEA” patients, CAS should be considered (Class IIa, level B), provided documented perioperative stroke/death rates are <3%. UpToDate recommends CEA in patients with ≥80% stenosis or patients with progression of stenosis to ≥80% stenosis.
Recent study showed that in asymptomatic patients, carotid revascularization either CEA or CASE does not portent a higher risk of adverse effect in women than in men.
Cochrane review (2020) comparing CEA versus CAS in this group of patients showed similar short-term and long-term outcomes (risk of stroke or death) however the certainty of the evidence in these people was only moderate.
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