An asymptomatic 66-year-old man is found to have a 75% internal carotid artery stenosis on duplex performed for a cervical bruit. He has no history of stroke or transient ischaemic attack. Neurologist assessment and imaging show no cerebral infarct. According to the ACAS trial, what is the appropriate recommendation?
- A Carotid endarterectomy, provided the centre's perioperative stroke and death rate is below about 3 percent ✓
- B Carotid endarterectomy regardless of operator outcome data, since all patients benefit equally
- C Best medical therapy alone, because endarterectomy has no proven benefit in asymptomatic stenosis
- D Carotid artery stenting as the preferred first-line revascularisation
Correct answer: A. Carotid endarterectomy, provided the centre's perioperative stroke and death rate is below about 3 percent
Explanation
The ACAS trial showed that carotid endarterectomy significantly reduces the five-year risk of ipsilateral stroke in asymptomatic stenosis of 60 percent or greater, but the benefit depends entirely on a perioperative stroke and death rate below roughly 3 percent. Best medical therapy alone forfeits this reduction, and stenting was not the tested modality and carries higher periprocedural risk in this group. Indian exam convention accepts the 60 percent threshold with the low-complication caveat.
Reference: Bailey and Love's Short Practice of Surgery, 28th ed.
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Written and medically reviewed by the StethoPrep medical team.