Surgical vs medical treatment for isolated internal carotid artery elongation with coiling or kinking in symptomatic patients: A prospective randomized clinical study

Whether surgically correcting symptomatic carotid elongation with coiling or kinking in the absence of an atherosclerotic lesion of the carotid bifurcation (isolated elongation) is effective in preventing stroke remains a controversial issue. The hypothesis behind this study was that surgical correction of symptomatic isolated carotid elongation with coiling or kinking could yield better results, in terms of stroke prevention and freedom from late stroke or carotid occlusion, than medical treatment. We conducted a prospective clinical study randomly assigning symptomatic patients with isolated carotid elongation to undergo either elective surgery or medical treatment, with surgery reserved for any new onset or worsening of symptoms. The follow-up ranged from 1 month to 10 years (median, 5.9; mean, 6.2 years) and was obtained for all patients. The study end points were perioperative (30-day) stroke and mortality, late stroke, and stroke-related death and late carotid occlusions. Ninety-two patients were randomly assigned for surgery and 90 for medical treatment. Overall, 139 carotid surgical corrections were performed in 129 patients. All 92 patients in the surgical arm had an elective operation; 10 of these patients later developed symptoms on the opposite side (7 hemispheric and 3 retinal transient ischemic attacks) and had contralateral internal carotid artery surgery. An additional 37 patients (41.1%) randomly assigned to medical treatment crossed over to the surgical group within a mean of 16.8 months after randomization due to new hemispheric symptoms or worsening nonhemispheric complaints. There were no perioperative strokes or deaths. The incidence of late hemispheric and retinal transient ischemic attacks was significantly lower in the surgical than in the medical group, respectively, 7.6% (7 of 92) vs 21.1% (19 of 90) (P = .01) and 3.2% (3 of 92) vs 12.2% (11 of 90) (P = .03). Late strokes, 2 (2.2%) of which were fatal, occurred only in the medical group (6 of 90, 6.6%; P = .01). Late carotid occlusions also developed only in the medical group (5 of 90, 5.5%; P = .02). All surgically treated carotid elongations were analyzed histologically and 78 (56.%) of 139 showed atypical and typical patterns of fibromuscular dysplasia. The overall results of this trial indicate that surgical correction of symptomatic isolated carotid elongations with coiling or kinking is better for stroke prevention than medical treatment.