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Safer Care Victoria’s Best Care resources support patients and healthcare providers to have conversations and make decisions together about the most appropriate pathways for care.

This resource, developed for clinicians, details a specific elective surgery procedure that should now only be done for specific indications. Evidence-based recommendations that detail ‘best care’ pathways should be discussed with your patient to determine the most appropriate pathway of care. 

Advice

In patients with asymptomatic carotid stenosis, carotid endarterectomy is generally not recommended.

When is the procedure indicated?

Some patients with asymptomatic carotid stenosis of greater than 70 per cent will benefit from carotid endarterectomy in addition to best medical management. 

Patient factors, plaque factors, choice of surgeon and institution perioperative stroke rate all determine this subset. Vascular surgeons are well placed to assess this information and make a decision in association with the patient and with input from a stroke physician if necessary. 

Best care recommendations

Medical therapy alone is recommended for most patients with asymptomatic carotid artery stenosis and has been associated with low annual stroke rates of less than 1 per cent.

In selected asymptomatic patients, carotid endarterectomy surgery may be indicated for patients who have carotid artery stenosis of greater than 70 per cent.

Evidence

Abbott AL. Medical (nonsurgical) intervention alone is now best for prevention of stroke associated with asymptomatic severe carotid stenosis: results of a systematic review and analysis. Stroke. 2009;40(10):e573-83. 

Halliday A, Harrison M, Hayter E, Kong XL, Mansfield A, Marro J, et al. 10-year stroke prevention after successful carotid endarterectomy for asymptomatic stenosis (ACST-1): a multicentre randomised trial. Lancet. 2010; 376(9746):1074-84. 

Johns Hopkins Medicine. Patient information – carotid endarterectomy. Baltimore (MD): John Hopkins Medicine; 2020 [cited 2020 Jun 22].

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(9420):1491-502. 

Raman G, Moorthy D, Hadar N, Dahabreh IJ, O'Donnell TF, Thaler DE, et al. Management strategies for asymptomatic carotid stenosis: a systematic review and meta-analysis. Annals of Internal Medicine. 2013;158(9):676-85.

Stroke Foundation. (Australian) Clinical guidelines for stroke management – chapter 4 of 8: Secondary prevention. Melbourne (VIC): 2020 Jun [cited 2020 Jun 22]. 

Page last updated: 23 Dec 2020

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