2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease: Executive Summary

Brott, Thomas G.; Halperin, Jonathan L.; Abbara, Suhny; Bacharach, J. Michael; Barr, John D.; Bush, Ruth L.; Cates, Christopher U.; Creager, Mark A.; Fowler, Susan B.; Friday, Gary; Hertzberg, Vicki; McIff, E. Bruce; Moore, Wesley S.; Panagos, Peter D.; Riles, Thomas S.; Rosenwasser, Robert H.; Taylor, Allen J.

doi:10.1161/cir.0b013e31820d8d78

Cited by 536 publications

(207 citation statements)

References 365 publications

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“…We observed similar reductions in rates of 5‐year events after carotid revascularization among statin users. Given these data, it is not surprising that major societal clinical practice guidelines recommend statin therapy in most patients undergoing carotid artery revascularization despite no specific randomized clinical trial data in this population 50, 51…”

Section: Discussionmentioning

confidence: 99%

Association Between Statin Use and Cardiovascular Events After Carotid Artery Revascularization

Hussain

Saposnik

Raju

et al. 2018

JAHA

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BackgroundStatins are commonly used for the prevention of cardiovascular events; however, statins are underutilized in patients with noncoronary atherosclerosis. We sought to establish the rates of statin use in patients with carotid artery disease and to examine the association between statin therapy and outcomes after carotid revascularization.Methods and ResultsIn this population‐level retrospective cohort study, we identified all individuals aged ≥66 years who underwent carotid endarterectomy or stenting in Ontario, Canada (2002–2014). The primary outcome was a composite of 1‐year stroke, myocardial infarction, or death (major adverse cardiac and cerebrovascular events). Five‐year risks were also examined. Adjusted hazard ratios were computed using inverse probability of treatment weighting based on propensity scores. A total of 7893 of 10 723 patients (73.6%) who underwent carotid revascularization were on preprocedural statin therapy; moderate‐ or high‐dose therapy was utilized by 7384 patients (68.9%). The composite rate of 1‐year major adverse cardiac and cerebrovascular events was lower among statin users (adjusted hazard ratio: 0.76; 95% confidence interval, 0.70–0.83). Patients who were on persistent long‐term statin therapy after the carotid procedure continued to experience significantly lower risk of major adverse cardiac and cerebrovascular events at 5 years (adjusted hazard ratio: 0.75, 95% confidence interval, 0.71–0.80). The beneficial associations with statin use were observed regardless of type of carotid revascularization procedure, carotid artery symptom status, or statin dose.ConclusionsContinuous statin therapy was associated with a 25% lower risk of long‐term adverse cardiovascular events in patients with significant carotid disease. Along with other supportive evidence, statins should be considered in patients undergoing carotid revascularization, and efforts are required to increase statin use in this undertreated population.

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Section: Discussionmentioning

confidence: 99%

Association Between Statin Use and Cardiovascular Events After Carotid Artery Revascularization

Hussain

Saposnik

Raju

et al. 2018

JAHA

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“…Successful recanalization with intravenous tissue plasminogen activator (tPA), the current stroke thrombolytic, is only achieved in 10% to 30% of patients with carotid occlusion 1, 2, 3. Although a severe carotid stenosis predicts a greater risk of stroke for any individual,4 the population frequency of mild stenosis is greater. Hence, acute occlusion of the carotid artery that leads to stroke may occur with varying degrees of carotid stenosis.…”

Section: Introductionmentioning

confidence: 99%

Thrombolytic Recanalization of Carotid Arteries Is Highly Dependent on Degree of Stenosis, Despite Sonothrombolysis

Tomkins

Hood

Pepperall

et al. 2016

JAHA

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BackgroundStroke associated with acute carotid occlusion is associated with poor effectiveness of tissue plasminogen activator (tPA) thrombolysis and poor prognosis. Rupture of atherosclerotic plaques resulting in vascular occlusions may occur on plaques, causing variable stenosis. We hypothesized that degree of stenosis may affect recanalization rates with tPA. Ultrasound+tPA (sonothrombolysis) has been shown to improve recanalization for intracranial occlusions but has not been tested for carotid occlusion. Our primary aim was to determine thrombolytic recanalization rates in a model of occlusion with variable stenosis, with a secondary aim to investigate sonothrombolysis in this model.Methods and ResultsRat carotid arteries were crushed and focal stenosis created (25% baseline Doppler flow) with a silk‐suture tie invoking thrombosis and occlusion. To model mild or severe stenosis, the tie was released pretreatment or left in place. Animals were treated with tPA (10 mg/kg) or tPA+ultrasound (2‐MHz) in each stenosis model (n=7/group). Recanalization was assessed by Doppler flow. Thrombolytic recanalization rates were significantly higher in mild stenosis groups (71% versus 0% with severe stenosis; P<0.0001). Recanalization rates were not significantly higher with additional ultrasound in either model.ConclusionsIn this model, the degree of carotid stenosis had a large effect on thrombolytic recanalization. Sonothrombolysis using standard parameters for intracranial sonothrombolysis did not increase recanalization. Further testing is warranted. The degree of underlying stenosis may be an important predictor of thrombolytic recanalization, and clinical correlation of these findings may provide new approaches to treatment selection for patients with carotid occlusion.

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“…First, the data comparing CAS and CEA are heterogeneous and subject to highly variable interpretations. The current literature has been used by professional societies and practitioners to both support as well as raise concern about the use of CAS for treatment of carotid stenosis 36, 37, 38, 39. Second, there are huge financial incentives at stake in the treatment of severe carotid disease.…”

Section: Lessons Learned From Carotid Artery Stentingmentioning

confidence: 99%

“…The risk–benefit issue is a little complex at the moment and should be discussed with patients in a transparent fashion to facilitate collaborative and individualized choice of treatment. The current ACC/AHA guidelines recommend CEA as the revascularization strategy of choice among low‐ or medium‐risk patients with significant carotid stenosis presenting with stroke or transient ischemic attack (Class I recommendation) 36. However, the guidelines also recognize CAS as an alternative to CEA (Class I recommendation) among patients who are at low risk for endovascular intervention, giving rise to controversy about patient selection 36.…”

Section: Lessons Learned From Carotid Artery Stentingmentioning

confidence: 99%

“…The current ACC/AHA guidelines recommend CEA as the revascularization strategy of choice among low‐ or medium‐risk patients with significant carotid stenosis presenting with stroke or transient ischemic attack (Class I recommendation) 36. However, the guidelines also recognize CAS as an alternative to CEA (Class I recommendation) among patients who are at low risk for endovascular intervention, giving rise to controversy about patient selection 36. Finally, the importance of optimal medical therapy and control of modifiable traditional cardiovascular risk factors cannot be ignored.…”

Section: Lessons Learned From Carotid Artery Stentingmentioning

confidence: 99%

See 1 more Smart Citation

Choice and Selection of Treatment Modalities for Cardiac Patients: An Interventional Cardiology Perspective

Agarwal

Tuzcu

Kapadia

2015

JAHA

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2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease: Executive Summary

Cited by 536 publications

References 365 publications

Association Between Statin Use and Cardiovascular Events After Carotid Artery Revascularization

Association Between Statin Use and Cardiovascular Events After Carotid Artery Revascularization

Thrombolytic Recanalization of Carotid Arteries Is Highly Dependent on Degree of Stenosis, Despite Sonothrombolysis

Choice and Selection of Treatment Modalities for Cardiac Patients: An Interventional Cardiology Perspective

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