An Update on Italian Stroke Organization Guidelines on Carotid Endarterectomy and Stenting

Abstract

One hundred and fifty-three authors, 45 Italian scientific societies, and two Italian patients' associations participated in drafting the Italian Stroke Organization document, which has become the national guideline for the prevention and treatment of stroke in Italy. For the surgical therapy section of the Italian Stroke Organization document, the main trials on carotid endoarterectomy and stenting were critically reviewed in order to formulate recommendations for these procedures. Recommendations are presented here for the referral of patients to either carotid endarterectomy or stenting on the basis of whether carotid stenosis is symptomatic or asymptomatic.

Systematic Review of Guidelines for the Management of Asymptomatic and Symptomatic Carotid Stenosis

“…[27][28][29][30][31][32][33][34][35][36][37][38][39]41,42,[46][47][48]50,51,[53][54][55][56][57][58][59]61,62 All 33 guidelines with procedural recommendations for SCS covered the moderate and severe ranges, except one which just covered the severe range (>70%) 40 and another that covered the moderate (50%-69%) range only if defined by conventional angiography. 41 Where the method of measuring SCS was indicated (17 guidelines), it was by the NASCET method 27,28,33,34,[36][37][38]40,41,[46][47][48][49]52,55,56,58,59 or by the NASCET or ECST method. [23][24...…”

“…28,[31][32][33]36,38,40,41,[44][45][46][47][50][51][52][53]55,56,58,61 Examples of high-CEA-risk because of medical comorbidities were age >80 years, New York Heart Association class III or IV heart failure, cardiac ejection fraction <30%, class III or IV angina, left main or multivessel coronary artery disease, severe uncorrectable coronary artery disease, myocardial infarction (MI) within 4 weeks, need for cardiac surgery within 30 days, severe lung disease and obesity. were used to substantiate a nonprocedural approach to ACS. …”

“…27,28,32,33,[35][36][37]58,63 In 1 of these, this recommendation was made only for patients aged >75 years.…”

“…27,28,32,33,[35][36][37]58 In 2 guidelines, CAS endorsement for average-CEA-risk, severe SCS was inconsistent or unclear. 29,58 Three guidelines recommended CAS for average-CEA-risk SCS when CEA was not available. …”

“…43 Referred to complications were generally stroke (of any type or localization) or death. [28][29][30]32,35,44,45,48,58,59 However, 2 guidelines referred to stroke, death, or MI. 41,60 In 12 guidelines (43%), the complications referred to were not fully specified because terms like morbidity were used.…”