Prevalence of High-risk Plaques and Risk of Stroke in Patients With Asymptomatic Carotid Stenosis

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Abstract
Over the past 3 decades, numerous randomized clinical trials have evaluated the benefits of carotid endarterectomy and stenting for stroke prevention in patients with asymptomatic carotid stenosis.1,2 In accordance with the results of those clinical trials, current international guidelines recommend considering revascularization in patients with severe asymptomatic carotid stenosis, provided that the periprocedural risk of ipsilateral ischemic cerebrovascular events is less than 3% (class 2a).3,4 However, critics assert that owing to improvements in best medical therapy, the risk of an ipsilateral ischemic cerebrovascular event among patients with asymptomatic carotid stenosis could now be lower than 1%, suggesting that revascularization may be harmful in some patients.5,6 As a consequence, the management of asymptomatic carotid stenosis has become a matter of debate, with some clinicians advocating for no revascularization outside of ongoing clinical trials.7-10 Several studies, including meta-analyses, have reported that extending the assessment of the features of carotid plaque beyond the degree of stenosis can help to select patients with asymptomatic carotid stenosis who have an increased risk of stroke and could therefore benefit from revascularization.11-24 However, owing to small samples and a low number of events, such studies have not provided data to indicate that the annual incidence of ipsilateral ischemic cerebrovascular events in patients with high-risk plaques exceeds the periprocedural risk of ipsilateral ischemic cerebrovascular events. Moreover, the studies have not provided an accurate estimate of the prevalence of high-risk plaque features to inform the design of clinical trials using a risk-oriented selection of patients before randomization. In this study, we provided estimates of the prevalence of plaques with high-risk features and the annual incidence of ipsilateral ischemic cerebrovascular events in patients with asymptomatic carotid stenosis.

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