Randall T. Higashida, M.D. Carotid Stenting: Carotid atherosclerotic disease is responsible for a significant proportion of major disabling strokes and death. Effective prevention by means of revascularization is the best course of treatment, if performed at a center with an acceptably low procedural complication rate. The ACAS, published in 1995, involved 1662 patients with asymptomatic carotid stenosis of more than 60%.1 Patients were prospectively, randomly assigned to undergo either surgical revascularization or aggressive medical management. The primary outcome was any major stroke or death; the median follow-up was 2.7 years. The aggregate risk of any stroke or perioperative death over a 5-year period favored revascularization (5.1%, vs. 11.0% for medical therapy; 95% confidence interval [CI], 0.9 to 9.1; relative risk reduction, 53.6%). The authors concluded that elective surgical revascularization will reduce the 5-year risk of ipsilateral stroke if performed at a center associated with a perioperative morbidity rate of less than 3%. In 2004, the results of the ACST, a confirmatory randomized trial of 3120 patients with asymptomatic stenosis of more than 60%, were published.2 An absolute reduction of 5.3% (95% CI, 3.0 to 7.8) in the rate of the primary end point — any stroke or perioperative death at 5 years — with early treatment translated into a significant relative risk reduction of 54.0% (P<0.001). p="0.004" p="0.053">
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