Cath Lab Digest

I was in Taipei last week where I participated in the 2011 Congress of the Asian Society for Vascular Surgery. I had the privilege of taking part in a session on carotid artery disease and my chosen topic for presentation was, “Carotid screening on asymptomatic patients: Should this practice end?”

It is no doubt a provocative subject and one that we definitely need to revisit at this time. The practice of carotid duplex scanning, and noninvasive vascular testing in general have exploded in recent years. And it is no longer just vascular and cardiovascular specialists doing this, but a host of other physicians – many with little real interest in or knowledge of vascular disease. A good number of “severe” or “critical” asymptomatic carotid lesions are being uncovered and, inevitably, such diagnosis leads to referral to a specialist for possible intervention, if not self-referral when the physician performing or conducting the scan is a vascular surgeon or interventionalist. Treatment of asymptomatic disease makes up 80% or more of the “carotid market” in this country, mostly via carotid endarterectomy.

The flipside is this: there are compelling recent data showing that asymptomatic carotid stenosis carries a remarkably low (<1%) risk of stroke on patients placed on optimal medical therapy that includes statins, hypertension control, glycemic control, and the like. Statins in particular appear to be making a huge difference in this regard. It is true though, that some patients may not fare as well, and we will need to learn more about identifying patients who would be worthy of an invasive intervention. Still, these patients are in the minority.

I would admit it is hard (even harsh) to “recommend” not to screen, and essentially to “ignore” whether a patient may have a severe carotid artery lesion. The reader would agree that once a significant stenosis is diagnosed, it is very difficult, if not impossible not to obtain (at a minimum) a consultation, and this often leads to surgery or intervention. The proliferation of surgery and stenting for asymptomatic stenosis is alarming and largely unnecessary. Worse yet, it exposes patients to more dangers than the natural history of the disease left alone (but managed with optimal medical therapy as described above).

Many voices are beginning to be heard in this space, and it is clear we need to take an honest second look at these issues, and question time-honored principles and practices that may not be serving our patients well.

These 2 references are just quick examples of the ongoing academic discussion; much more is needed, in the U.S. in particular:

Abbott AL. Medical (nonsurgical) intervention alone is now best for prevention of stroke associated with asymptomatic severe carotid stenosis: Results of a systematic review and analysis. Stroke. 2009 Oct;40(10):e573-583.

Naylor AR, Gaines PA, Rothwell PM. Who benefits most from intervention for asymptomatic carotid stenosis: Patients or professionals? Eur J Vasc Endovasc Surg. 2009 Jun;37(6):625-632.