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The detailed results of the Asymptomatic Carotid Atherosclerosis Study (ACAS) have been published. [1] Electrifying reports in the media suggested that 53% fewer strokes would occur if individuals with 60% or greater stenosis were submitted to endarterectomy. [2,3] The burning question is whether the evidence from this trial, and those preceding it, is sufficiently compelling to persuade any or all individuals with carotid stenosis, but free of any hemisphere and retinal symptoms, to have carotid endarterectomy. Based on a variety of population samplings, it is reasonable to estimate that approximately two million people are living in North America and Europe with asymptomatic lesions comparable with those studied in ACAS. [4-8]
Expansion of carotid endarterectomy to asymptomatic patients.
Carotid endarterectomy was introduced as a prophylaxis for ischemic stroke and was carried out initially on symptomatic patients. The recognition of the significance of carotid bruits, the development of noninvasive imaging of the neck arteries, and training of many surgeons capable of performing carotid endarterectomy spurred enthusiasm for its application to asymptomatic patients. The rationale for extending the procedure to patients before they have symptoms is reasonable. More patients present with stroke than with warning symptoms of a transient type. Carotid occlusion is the ultimate result of a progressing carotid stenosis. When occlusion occurs, with or without symptoms, it has the potential to deprive individuals who have poor collateral circulation of 25% of their cerebral circulation. The hope was that both stroke and occlusion might be obviated by early endarterectomy. Many surgical series, based on opinion and individual experience, began to appear, but the comparison with unoperated patients, as control subjects, was not convincing. [9,10]
Coronary artery bypass surgery is complicated often enough by cerebral ischemic events to promote the common practice of prophylactically removing the asymptomatic carotid stenosing lesion before or accompanying the cardiac procedure. This practice continues, although …
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