Comparative Review of the Treatment Methodologies of Carotid Stenosis

Abstract

The treatment of carotid stenosis entails three methodologies, namely, medical management, carotid angioplasty and stenting (CAS), as well as carotid endarterectomy (CEA). The North American Symptomatic Carotid Endarterectomy Trial (NASCET) and European Carotid Surgery Trial (ECST) have shown that symptomatic carotid stenosis greater than 70% is best treated with CEA. In asymptomatic patients with carotid stenosis greater than 60%, CEA was more beneficial than treatment with aspirin alone according to the Asymptomatic Carotid Atherosclerosis (ACAS) and Asymptomatic Carotid Stenosis Trial (ACST) trials. When CAS is compared with CEA, the CREST resulted in similar rates of ipsilateral stroke and death rates regardless of symptoms. However, CAS not only increased adverse effects in women, it also amplified stroke rates and death in elderly patients compared with CEA. CAS can maximize its utility in treating focal restenosis after CEA and patients with overwhelming cardiac risk or prior neck irradiation. When performing CEA, using a patch was equated to a more durable result than primary closure, whereas eversion technique is a new methodology deserving a spotlight. Comparing the three major treatment strategies of carotid stenosis has intrinsic drawbacks, as most trials are outdated and they vary in their premises, definitions, and study designs. With the newly codified best medical management including antiplatelet therapies with aspirin and clopidogrel, statin, antihypertensive agents, strict diabetes control, smoking cessation, and life style change, the current trials may demonstrate that asymptomatic carotid stenosis is best treated with best medical therapy. The ongoing trials will illuminate and reshape the treatment paradigm for symptomatic and asymptomatic carotid stenosis.

Carotid Restenosis Following Endarterectomy in Patients Managed With Single Antiplatelet Therapy Versus Dual Antiplatelet Therapy

“…6 -9 While low dose aspirin (81-325 mg/day) is recommended after carotid surgery, the role of dual antiplatelet therapy (DAPT) remains less clear. 5,10 -14…”

“…[6][7][8][9] While low dose aspirin (81-325 mg/day) is recommended after carotid surgery, the role of dual antiplatelet therapy (DAPT) remains less clear. 5,[10][11][12][13][14] Carotid restenosis following endarterectomy has been reported in up to 20% of cases, with more recent studies reporting rates of less than 10%. 1,[15][16][17][18] While some studies have found reduced stoke rates when clopidogrel and aspirin are administered in combination, these results have not been reproduced in larger studies and have yet to be tested in a randomized trial.…”

Association between low levels of serum miR-638 and atherosclerotic plaque vulnerability in patients with high-grade carotid stenosis

“…Several preventive measures have been developed to treat carotid artery stenosis, such as surgical plaque removal by carotid endarterectomy (CEA), endovascular stent placement, 26,28 and/or pharmacological treatment. 2 Nevertheless, the surgical management of asymptomatic patients with ≥ 70% carotid artery stenosis and < 10 years of life expectancy is highly controversial due to the improvement of the medical treatment. 13,25 The degree of carotid artery stenosis and plaque neovascularization, evaluated through imaging techniques such as contrast-enhanced ultrasound, positron emission tomography/computed tomography (PET/CT), and MRI, is being considered a most important predictor of carotid plaque vulnerability and, consequently, of increased risk of stroke in patients with carotid artery disease.…”

Gene expression analysis: Regulation of key genes associated with mycophenolate mofetil treatment of symptomatic carotid artery stenosis

“…The treatment of CAS includes three modalities: Medical management, carotid artery angioplasty and stenting, and CEA ( 26 ). However, there are doubts regarding the efficacy of carotid artery angioplasty and stenting, and CEA, in specific patients ( 27 – 29 ).…”