Cath Lab Digest

The advent of best medical treatment and advances in carotid artery stenting has created equipoise for surgical versus medical/endovascular management of carotid artery disease. Most vascular specialists agree that symptomatic carotid stenosis >70% needs carotid endarterectomy unless those patients are too high-risk for surgery. The controversies exist for asymptomatic carotid artery disease of >60%. The old recommendations based on ACAS trial are outdated. Vascular physicians agree that asymptomatic carotid artery stenosis of >80% will need carotid artery revascularization. However few believe that medical treatment alone should suffice, especially in females and the elderly. Some data from clinical trials show that the best medical treatment patients with carotid artery stenosis can have stroke if there is an unstable plaque. Patterns with “hits” on transcranial Doppler during the follow-up had higher incidence of stroke or TIA.

Several opportunities arise as potential projects for research to diagnose those at risk for stroke with asymptomatic carotid artery disease:

1. Use of small nitinol wire-based heat probe to check the temperature of the plaque. If the plaque is unstable, those patients will need treatment or continuation of medical treatment. Such technology is available in coronary lesion evaluation as a research method.
2. Miniaturized 24 H transcranial Doppler that the patient can take home. If the Doppler shows increased hits, then the patient needs carotid revascularization.
3. Advanced MRI and CT that can characterize a vulnerable plaque with molecular imaging.

We believe that advances in medical treatment, especially statins, will reduce the need for carotid artery revascularizations especially in asymptomatic patients.