Asymptomatic patients with high-risk carotid stenosis may benefit from carotid endarterectomy (CEA), according to a randomized controlled trial published in The Lancet medical journal (Lancet. 2004;363:1486-1487, 1491-1502). ”Our trial suggests that immediate surgery is the best option for some patients with severe carotid stenosis,” said first author Alison Halliday of St. George’s Hospital, London, U.K. In a press release, “How important the approach is depends on how long the benefit obtained lasts We will therefore follow these patients for a further five years. They acknowledged that it is controversial whether CEA should be performed in patients with carotid stenosis without stroke or transient ischemia. Between 1993 and 2003, 3,120 patients in 126 hospitals in 30 countries were randomized to CEA or drug therapy (including antihypertensives, anticoagulants, and lipid-lowering drugs) and then followed prospectively for 5 years, with a mean follow-up of 3.4 years. The risk of stroke or death within 30 days of surgery was 3.1%; for patients younger than 75 years of age who underwent surgery, the 5-year risk of stroke was 6.4%; and for drug therapy it was 11.8% (P < .0001). Although these results suggest that CEA reduces the risk in high-risk asymptomatic patients, the authors warn that there is a risk of stroke if the procedure itself is not performed by a specialist. Accompanying review author Henry Barnett of the John Robert Institute in Ontario, Canada, examined the results of some of the earlier trials and discussed the factors that determine whether surgery or medication should be used to treat carotid stenosis. "While there are still questions, these researchers should be congratulated for a job well done," he said, "but if the carotid surgeon is not skilled enough, the method can quickly become a risk factor for stroke.