[Treatment of asymptomatic carotid stenoses: evolution of ideas, medical treatment, surgical treatment, what about percutaneous transluminal angioplasty?].
Asymptomatic carotid lesions treatment techniques have not greatly evolved over the last 15 years. Although there seems to be a consensus to apply only medical treatment for lesions less than 60-70%, there is still debate with regards to patient cohort suffering from high-grade stenosis (between 70% and 90%). Very high-grade lesions seem, however, to benefit from surgery. The most significant improvements come from Duplex scan and non-invasive radiology (TDM with injection and MRI) allowing a more accurate stenosis measurement and above all, detection of potential high-risk lesion (inhomogeneous plaque, haematoma under plaque). Medical treatment as well as risk factor balancing is always complementary to surgery. The most significant improvement is probably the anaesthesiology technique with the wide use of local analgesia allowing an ideal cerebral protection. The various surgical techniques: simple endarterectomy or with patch, eversion endarterectomy, venous or prosthetic by-pass show no significant difference either in the immediate results or in restenosis. These techniques enabled a mortality rate of less than 1% (due to a better cardiac check-up) and morbidity rate of less than 2%. The development of percutaneous transluminal angioplasty with stenting (secured by protection devices) has made indications slightly more difficult by adding a non-validated technique which has not proven its merits compared to surgery. One of the dangers from this technique is that it may lead to abusive indications. In summary, surgery is the most adequate treatment for high-grade asymptomatic carotid lesions after a precise locoregional check-up, especially a cardiac one. Medico legal implications in this asymptomatic situation call for precise and honest patient information.
Agé
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B
Service de chirurgie vasculaire, clinique Jeanne-d'Arc, 44, cours Albert-Thomas, 69008 Lyon, France. brunoage@aol.com
D000768:Anesthesia, General / Q000379:methods; D000800:Angioplasty, Balloon; D016893:Carotid Stenosis / Q000150:complications / Q000175:diagnosis / Q000601:surgery; D004691:Endarterectomy / Q000379:methods*; D006801:Humans; D018810:Magnetic Resonance Angiography; D011379:Prognosis; D012307:Risk Factors; D012720:Severity of Illness Index; D020521:Stroke / Q000209:etiology / Q000517:prevention & control; D018616:Ultrasonography, Doppler, Duplex