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Topic 1113 Version 48.0 https://www.uptodate.com/contents/management-of-asymptomatic-extracranial-carotid-atherosclerotic-disease/print 29/35 7/5/23, 11:40 AM Management of asymptomatic extracranial carotid atherosclerotic disease - UpToDate GRAPHICS Carotid endarterectomy reduces stroke, but not endpoint of stroke and death, in asymptomatic men Medical versus surgical (carotid endarterectomy) therapy in 444 men with asymptomatic carotid stenosis 50 percent. (Top panel) Carotid endarterectomy reduced the four-year incidence of ipsilateral stroke or TIA compared to medical therapy (8 versus 20.6 percent, p<0.001). (Bottom panel) There was no difference between the two groups in the incidence of stroke and death (41 versus 44 percent). TIA: transient ischemic attack. Data from: Hobson RW, Weiss DG, Fields WS, et al. E cacy of carotid endarterectomy for asymptomatic carotid stenosis. The Veterans A airs Cooperative Study Group. N Engl J Med 1993; 328:221. Graphic 53736 Version 7.0 https://www.uptodate.com/contents/management-of-asymptomatic-extracranial-carotid-atherosclerotic-disease/print 30/35 7/5/23, 11:40 AM Management of asymptomatic extracranial carotid atherosclerotic disease - UpToDate Carotid endarterectomy in asymptomatic men In the ACAS trial, 1662 patients with an asymptomatic carotid stenosis 60 percent were randomized to medical therapy with aspirin or CEA and followed for a mean of 2.2 years. (Top panel) There was no difference between the two groups in the incidence of major stroke or death. (Bottom panel) The incidence of any ipsilateral TIA or stroke or death was lower in the surgical group (p = 0.004). CEA: carotid endarterectomy; TIA: transient ischemic attack. Data from: Executive Committee for the Asymptomatic Carotid Atherosclerosis Trial. JAMA 1995; 273:1421. Graphic 54275 Version 4.0 https://www.uptodate.com/contents/management-of-asymptomatic-extracranial-carotid-atherosclerotic-disease/print 31/35 7/5/23, 11:40 AM Management of asymptomatic extracranial carotid atherosclerotic disease - UpToDate Any type of stroke or perioperative death in the Asymptomatic Carotid Surgery Trial Risk of any stroke and perioperative death in ACST. The net five-year risk for all strokes or perioperative death in the CEA group was reduced by nearly half compared with the CEA deferral group. ACST: Asymptomatic Carotid Surgery Trial; CEA: carotid endarterectomy. Reproduced with permission from: MRC Asymptomatic Carotid Surgery Trial (ACST) Collaborative Group. Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomised controlled trial. Lancet 2004; 363:1491. Copyright 2004 Elsevier. Graphic 51041 Version 7.0 https://www.uptodate.com/contents/management-of-asymptomatic-extracranial-carotid-atherosclerotic-disease/print 32/35 7/5/23, 11:40 AM Management of asymptomatic extracranial carotid atherosclerotic disease - UpToDate Fatal or disabling stroke or perioperative death in the Asymptomatic Carotid Surgery Trial The risk of fatal or disabling stroke or perioperative death in the ACST. The net five-year risk for fatal or disabling strokes or perioperative death in the CEA group was reduced by nearly half compared with the CEA deferral group. About one-half of the strokes in the trial were fatal or disabling. ACST: Asymptomatic Carotid Surgery Trial; CEA: carotid endarterectomy. Reproduced with permission from: MRC Asymptomatic Carotid Surgery Trial (ACST) Collaborative Group. Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomised controlled trial. Lancet 2004; 363:1491. Copyright 2004 Elsevier. Graphic 64869 Version 6.0 https://www.uptodate.com/contents/management-of-asymptomatic-extracranial-carotid-atherosclerotic-disease/print 33/35 7/5/23, 11:40 AM Management of asymptomatic extracranial carotid atherosclerotic disease - UpToDate Meta-analysis of ACAS and ACST The effect of endarterectomy for asymptomatic carotid stenosis on the risk of any stroke and operative death by sex in the ACST and ACAS trials. ACST: Asymptomatic Carotid Surgery Trial; ACAS: Asymptomatic Carotid Atherosclerosis Study; CI: confidence interval; OR: odds ratio. Reproduced with permission from: Rothwell PM, Goldstein LB. Carotid endarterectomy for asymptomatic carotid stenosis: asymptomatic carotid surgery trial. Stroke 2004; 35:2425. Copyright 2004 Lippincott Williams & Wilkins. Graphic 80838 Version 11.0 https://www.uptodate.com/contents/management-of-asymptomatic-extracranial-carotid-atherosclerotic-disease/print 34/35 7/5/23, 11:40 AM Management of asymptomatic extracranial carotid atherosclerotic disease - UpToDate Contributor Disclosures Michael T Mullen, MD Grant/Research/Clinical Trial Support: NINDS [Asymptomatic carotid disease]. All of the relevant financial relationships listed have been mitigated. Jeffrey Jim, MD, MPHS, FACS Consultant/Advisory Boards: Endospan [Aortic interventions]; Medtronic [Aortic interventions]; Silk Road Medical [Carotid stent]. All of the relevant financial relationships listed have been mitigated. Scott E Kasner, MD Grant/Research/Clinical Trial Support: Bayer [Stroke]; Bristol Meyers Squibb [Stroke]; Medtronic [Stroke]; WL Gore and Associates [Stroke]. Consultant/Advisory Boards: Abbvie [Stroke]; AstraZeneca [Stroke]; BMS [Stroke]; Diamedica [Stroke]; Medtronic [Stroke]. All of the relevant financial relationships listed have been mitigated. John F Eidt, MD Grant/Research/Clinical Trial Support: Syntactx [Clinical events, data/safety monitoring for medical device trials]. All of the relevant financial relationships listed have been mitigated. Joseph L Mills, Sr, MD No relevant financial relationship(s) with ineligible companies to disclose. John F Dashe, MD, PhD No relevant financial relationship(s) with ineligible companies to disclose. Kathryn A Collins, MD, PhD, FACS No relevant financial relationship(s) with ineligible companies to disclose. Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence. 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