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Although there is level I evidence supporting the role of carotid endarterectomy (CEA) in patients with asymptomatic disease, opinion remains polarised regarding what constitutes optimal management, especially as carotid artery stenting (CAS) has emerged as a less invasive alternative. Reasons for this lack of consensus amongst surgeons, interventionists, neurologists and stroke physicians include our continued inability to identify 'high risk for stroke' patients in whom to target costly therapies. For example, recent data from the USA suggest that up to $21 billion is being spent each year on ultimately 'unnecessary' interventions. Second, is growing evidence that improvements in what now constitutes modern 'best medical therapy' has significantly reduced the risk of stroke compared to that observed in ACAS and ACST. If true, this will compromise risk:benefit analyses used in national and international guidelines. At a time when evidence suggests that up to 94% of interventions may not benefit the patient, the authors urge that at least one of the randomised trials comparing CEA with CAS in asymptomatic patients includes an adequately powered third limb for BMT. Timely investment now could optimise patient care and resource utilisation for all of us in the future.

Original publication

DOI

10.1016/j.ejvs.2009.01.026

Type

Journal article

Journal

Eur J Vasc Endovasc Surg

Publication Date

06/2009

Volume

37

Pages

625 - 632

Keywords

Angioplasty, Cardiovascular Agents, Carotid Stenosis, Cost-Benefit Analysis, Endarterectomy, Carotid, Evidence-Based Medicine, Health Care Costs, Humans, Patient Selection, Practice Guidelines as Topic, Randomized Controlled Trials as Topic, Research Support as Topic, Risk Assessment, Stents, Stroke, Treatment Outcome, Unnecessary Procedures