New Research Suggests Medication May Replace Surgery for Carotid Artery Stenosis

Recent findings from a collaborative study led by University College London (UCL), along with Amsterdam UMC and the University of Basel, indicate that a substantial number of patients who experience a stroke caused by carotid artery stenosis might be effectively managed with medication alone, potentially eliminating the need for risky surgical interventions.

This pivotal research, published in The Lancet Neurology, could prompt a significant shift in global treatment guidelines for these patients. In the Netherlands alone, approximately 2,000 individuals undergo surgery annually due to carotid artery narrowing following a stroke. Previous studies conducted three decades ago established that such surgeries could significantly decrease the likelihood of recurrent strokes, leading to their adoption as the standard treatment.

Over the years, advancements in medications provided to these patients--including blood thinners and treatments for cholesterol and hypertension--have progressed considerably. Given this context, researchers, including neurologist Paul Nederkoorn from Amsterdam UMC, sought to determine whether routine surgeries remain essential for all patients suffering from this condition.

The study, known as the ECST study, involved a comprehensive examination of 429 patients across 30 centers in Europe and Canada between 2012 and 2019. All participants had a low to moderate risk of experiencing another stroke within two years following their initial treatment. Patients categorized as high-risk were excluded due to uncertainties surrounding the efficacy of medication alone in their cases.

Participants were divided into two groups: one receiving only medication and the other undergoing standard surgical procedures in addition to medication. After two years, researchers assessed various outcomes, including the incidence of new strokes, heart attacks, and unnoticed strokes detected through MRI scans.

The results showed comparable outcomes between the two groups, leading to the conclusion that surgical intervention may not be necessary for this specific cohort when treated with optimized medical therapy.

Emeritus Professor Martin Brown from UCL emphasized the importance of personalized assessment and intensive management of vascular risk factors, suggesting that this approach could spare many patients from the discomfort and risks associated with surgery, while also yielding substantial cost savings for healthcare systems.

Future research is expected to identify which patients possess such a high risk of subsequent strokes that they would still require surgical intervention. Innovations in imaging techniques for atherosclerotic plaque in the carotid artery are anticipated to enhance the selection process for high-risk patients, enabling a more tailored treatment approach.

As a result of these findings, the researchers predict that both national and international treatment guidelines will soon be revised to reflect this emerging evidence. At Amsterdam UMC, collaboration with vascular surgeons is already underway to adapt current protocols for low- and medium-risk patients, moving away from routine surgeries.