CONSENSUS AGAINST BOTH ENDARTERECTOMY AND ROUTINE SCREENING FOR ASYMPTOMATIC CAROTID-ARTERY STENOSIS

Background: Despite several randomized controlled trials, the role of carotid endarterectomy for asymptomatic patients is controversial. Val idated evidence-based guidelines are needed. Methods: Thirty-five memb ers of the Canadian Stroke Consortium, an independent body of cerebrov ascular disease experts, reviewed evidence-based guidelines developed by the Canadian Task Force on the Periodic Health Examination. We held 3 rounds of Delphi consensus to solicit opinion and agreement. Result s: We found a high level of interrater agreement for all guidelines us ing multiple statistical measures. Members agreed that evidence is ins ufficient to endorse carotid endarterectomy for asymptomatic patients with angiographically proven stenosis of more than 60% (kappa=0.70, P< .01). Reasons cited included concern over the reproducibility of low s urgical morbidity rates in the community at large, the questionable cl inical benefit conferred by surgery, and the lack of proven reduction in the risk of major disabling stroke. Screening the general populatio n for asymptomatic stenosis was unanimously rejected. Also, screening even patients with risk factors or proven atherosclerosis at other sit es was not endorsed (kappa=0.91 and kappa=0.79, respectively, both P<. 01).Conclusions: There is insufficient evidence to recommend carotid e ndarterectomy for asymptomatic patients. Evidence is also insufficient to endorse a screening strategy even for patients with risk factors f or carotid disease. While stroke prevention remains a critical goal, w e do not recommend that it be accomplished by screening or by performi ng carotid surgery in asymptomatic patients.