If a doctor tells you you have a narrowing in your carotid artery – the big blood vessel in the neck that supplies the brain – you will require surgery to clear the blockage, right?
You haven’t had a stroke as a result of the narrowing, which may have been picked up as part of an ultrasound screening or because the doctor, as part of a clinical examination, hears a noise in the artery. But you can’t carry on, running the risk of a small piece of fatty material breaking off and travelling up to your brain, and ignore the blockage – can you?
You would expect to be referred to see a vascular surgeon who will decide whether you will benefit from having the plaque cleaned out in an open surgery procedure called a carotid endarterectomy (CEA) or whether you might be suitable for a less invasive carotid artery stenting (CAS). In this procedure, the surgeon passes a catheter up through an incision in the groin, inflates a balloon to push the plaque back into the vessel wall, and then puts a small wire mesh coil (a stent) into the vessel to keep the artery from narrowing again.
But there is another option, depending on where in the world you live.
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In the US, it’s highly likely that you will be operated on. In parts of Europe or Australia, the first treatment is usually intensive medical therapy using cholesterol-lowering and blood-thinning drugs. There is a huge geographic variation in the approach to asymptomatic stenosis of the carotid artery.
Just as we have moved away from stenting every coronary artery blockage to prevent future heart attack in patients, there is evidence now that the risk of stroke, even when the carotid artery occludes totally, is rare (less than 1 per cent). But the risk of a perioperative stroke – one that occurs during or immediately after surgery – can be as high as 5 per cent.
Interestingly, and perhaps counterintuitively, higher stroke rates have been associated with CAS compared with CEA for as long as patients have been followed up in randomised clinical trials.
But back to the benefits of medical therapy combined with watchful waiting in the person with asymptomatic carotid artery disease. Research published last month in the New England Journal of Medicine (hat tip to Dr John Mandrola, writing in the Sensible Medicine Substack) is described as a “major medical reversal in vascular surgery”.
The CREST 2 trial, involving some 2,500 patients across the US, provided big surprises in the treatment of patients with asymptomatic carotid artery disease.
Researchers enrolled patients with asymptomatic carotid stenosis with a greater than 70 per cent blockage in the artery to two parallel arms in the trial: one was intensive medical management (IMM) + CAS vs IMM alone, and the other arm was IMM + CEA vs IMM alone.
Intensive medical management focused on blood pressure and blood glucose reduction along with cholesterol reduction using medications. Stenting and surgeries were done by experts in centres of excellence. The patients were followed up for four years.
The results are striking.
From day 0 to 44, in the stenting arm of the trial, no strokes or deaths occurred in the medical-therapy group and seven strokes and one death occurred in the stenting group; in the endarterectomy arm, three strokes occurred in the medical-therapy group and nine strokes occurred in the endarterectomy group.
Dr Mandrola had this to say about CREST 2: “If you have a patient with an asymptomatic carotid lesion, you get serious about medical therapy (including lifestyle advice) and follow the patient closely. You inform the patient what symptoms may look like and intervene when and if symptoms occur.”
The study makes it clear there is little to no benefit from elective surgery.
If a doctor tells you that they have discovered a narrowing in your carotid artery, maybe tell them you will take the tablets but will decline the knife.
