Forty years of carotid decision-making rest on a single number measured off a still image. Here is the case for replacing it.
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The NASCET measurement is one of the most successful pieces of clinical measurement in vascular medicine, and it is also the reason carotid research stalled. It gave us a threshold, the threshold gave us a trial, and the trial gave us a guideline. After that there was very little incentive to ask what the number was actually standing in for.
What it is standing in for is flow. A narrowing matters because of what it does to the velocity field downstream of it, and two anatomically identical narrowings in differently shaped bifurcations do quite different things to that field. This is not a controversial claim in fluid mechanics. It is only controversial in clinic because we have not had a way to measure it on a routine scan.
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