An asymptomatic 67-year-old man is found to have a 70% internal carotid artery stenosis on duplex performed for a cervical bruit. He has no neurological history. Based on the ACAS trial, what is the most appropriate management?

• A Serial duplex every three months until symptoms develop
• B Best medical therapy alone, since surgery benefits only symptomatic patients
• C Urgent carotid artery stenting within four weeks
• D Carotid endarterectomy if perioperative stroke and death risk is under 3% ✓

Explanation

The ACAS trial showed that in asymptomatic men with stenosis of 60% or more, carotid endarterectomy combined with medical therapy reduced five-year ipsilateral stroke risk compared with medical therapy alone, provided perioperative morbidity and mortality stayed below 3%. Best medical therapy alone ignores the demonstrated absolute benefit, and stenting was not superior to endarterectomy in CREST for this group.

Reference: Sabiston Textbook of Surgery, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.