Carotid revascularization: risks and benefits

Abstract

Despite a decline during the recent decades in stroke-related death, the incidence of stroke has remained unchanged or slightly increased, and extracranial carotid artery stenosis is implicated in 20%–30% of all strokes. Medical therapy and risk factor modification are first-line therapies for all patients with carotid occlusive disease. Evidence for the treatment of patients with symptomatic carotid stenosis greater than 70% with either carotid artery stenting (CAS) or carotid endarterectomy (CEA) is compelling, and several trials have demonstrated a benefit to carotid revascularization in the symptomatic patient population. Asymptomatic carotid stenosis is more controversial, with the largest trials only demonstrating a 1% per year risk stroke reduction with CEA. Although there are sufficient data to advocate for aggressive medical therapy as the primary mode of treatment for asymptomatic carotid stenosis, there are also data to suggest that certain patient populations will benefit from a stroke risk reduction with carotid revascularization. In the United States, consensus and practice guidelines dictate that CEA is reasonable in patients with high-grade asymptomatic stenosis, a reasonable life expectancy, and perioperative risk of less than 3%. Regarding CAS versus CEA, the best-available evidence demonstrates no difference between the two procedures in early perioperative stroke, myocardial infarction, or death, and no difference in 4-year ipsilateral stroke risk. However, because of the higher perioperative risks of stroke in patients undergoing CAS, particularly in symptomatic, female, or elderly patients, it is difficult to recommend CAS over CEA except in populations with prohibitive cardiac risk, previous carotid surgery, or prior neck radiation. Current treatment paradigms are based on identifying the magnitude of perioperative risk in patient subsets and on using predictive factors to stratify patients with high-risk asymptomatic stenosis.

The Possibilities of Using a New Fixed-Dose Combination of Rosuvastatin and Acetylsalicylic Acid: Focus Groups of Patients

“…Частота атеросклероза сонных артерий увеличивается с возрастом: у пациен-тов старше 70 лет бессимптомный стеноз каротидных артерий (более 50% просвета сосуда) отмечается у 7% женщин и более 12% мужчин [7].…”

“…В целом, у пациентов с бессимптомным стенозом сонных артерий риск гомолатерального инсульта со-ставляет в среднем 2-5% в год [7], у больных же с на-личием симптомного каротидного атеросклероза риск инсульта в течение двух лет даже при наличии опти-мального медикаментозного лечения оценивается в 26% [7]. Риск ИИ возрастает по мере прогрессирова-ния стеноза сонных артерий.…”

Clinical Comparison of Outcomes of Early versus Delayed Carotid Artery Stenting for Symptomatic Cerebral Watershed Infarction due to Stenosis of the Proximal Internal Carotid Artery

“…Previous studies have demonstrated that 20% of ischemic strokes are associated with extracranial carotid artery stenosis [1, 2]. Severe stenosis of proximal internal carotid artery can cause ipsilateral cerebral watershed infarction [3].…”

“…For patients with carotid artery stenosis, medical therapy and risk factor regulation are considered as first-line treatments. In recent decades, many clinical trials have demonstrated the benefits of carotid revascularization using carotid artery stenting (CAS) or carotid endarterectomy (CEA) in patients with symptomatic carotid stenosis more than 70% [2, 4]. Currently, CAS has become an acceptable treatment methods alternative to the standard CEA.…”

Early Carotid Artery Stenting for Cerebral Watershed Infarction Is Safe and Effective: A Retrospective Study

“…For patients with carotid artery stenosis, medical therapy and risk factor regulation are first-line treatments. In recent decades, many clinical trials have demonstrated the benefits of performing carotid revascularization, which include either carotid artery stenting (CAS) or carotid endarterectomy (CEA), in the symptomatic patient population with carotid stenosis of >70% [2]. However, the question of when to perform carotid revascularization after acute ischemic stroke is still under debate.…”