asymptomatic carotid notes

Carotid atherosclerotic disease

Symptomatic or asymptomatic?

Symptomatic -
-focal neurological symptoms
-refer to appropriate distribution
-1+ TIA/Stroke
-w/in last six months

*vertigo and syncope not generally caused by carotid stenosis


Asymptomatic
-trials have established CEA for asymptomatic men w/ ICA stenosis >60% w/life expectancy >5yrs with perioperative risk of death <3%.
Woman? medical management

aspirin recommended for all having CEA

Three trials VA, ACAS, ACST
1993 -VA - absolute risk reduction was 1% over 4 year follow up
444 men w/50-99% stenosis (assessed w/arteriogram)
randomized to aspirin or aspirin + CEA, mean 48 month follow-up
results
-decreased stroke/TIA
stroke or TIA decreased 8 vs 20.6%
pertinent negative: no difference in ipsilateral stroke
no different in combine stroke/death at 4 years (41 v 44%)

1995- ACAS - absolute risk reduction was 3% over 2.7yrs
1662 adults w/60-99% stenosis to ASA325 vs ASA+CEA
end point was ipsi infarction or death in perioperative period
results
-ipsi stroke/peri stroke or death 5 v 11 @ median f/u 2.7
Men had ARR of 8% women 1.4% 2/2 periop complications
-subgroup analysis - less effective in women (but not significant)

ACST - absolute risk reduction 3.1% over 3.4 yrs
3120 patients w/>60% asymptomatic, there was an immediate surgery and versus deferral group vs medical management.
-@3.4 yrs - CEA perioperative death/stroke was 3.1% w/in 30 days
-immediate > deferral @5yrs 6.4 v 11.8 for strokes and periop death
-ARR >men