Comparison of Recent Practice Guidelines for the Management of Patients With Asymptomatic Carotid Stenosis

Abstract

Despite the publication of several national/international guidelines, the optimal management of patients with asymptomatic carotid stenosis (AsxCS) remains controversial. This article compares 3 recently released guidelines (the 2020 German–Austrian, the 2021 European Stroke Organization [ESO], and the 2021 Society for Vascular Surgery [SVS] guidelines) vs the 2017 European Society for Vascular Surgery (ESVS) guidelines regarding the optimal management of AsxCS patients. The 2017 ESVS guidelines defined specific imaging/clinical parameters that may identify patient subgroups at high future stroke risk and recommended that carotid endarterectomy (CEA) should or carotid artery stenting (CAS) may be considered for these individuals. The 2020 German–Austrian guidelines provided similar recommendations with the 2017 ESVS Guidelines. The 2021 ESO Guidelines also recommended CEA for AsxCS patients at high risk for stroke on best medical treatment (BMT), but recommended against routine use of CAS in these patients. Finally, the SVS guidelines provided a strong recommendation for CEA+BMT vs BMT alone for low-surgical risk patients with >70% AsxCS. Thus, the ESVS, German–Austrian, and ESO guidelines concurred that all AsxCS patients should receive risk factor modification and BMT, but CEA should or CAS may also be considered for certain AsxCS patient subgroups at high risk for future ipsilateral ischemic stroke.

Risk Factors for Carotid Restenosis in Patients After Eversion Endarterectomy vs Stenting: A Single-Center Experience

“…Data were obtained from medical records acquired from electronic health systems. The data included: (1) basic demographic data on age and sex, (2) clinical presentation and course of the disease, (3) anthropometric parameters, (4) basic biochemistry (triglycerides, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), hemoglobin, and creatinine), (5) degree of stenosis in affected carotid artery (I: 50-69%; II: 70-79% III: 80-90%; IV: >90%), (6) type of plaque in affected carotid artery (I: stable; II: fibrous; III: calcified; IV: ulcerated; V: echolucent), (7) treatment (preoperative; postoperative), (8) early postoperative complications, (9) postoperative symptoms, and 10) degree of carotid restenosis (I: no restenosis; II: <50%; III: ≥50%). Risk factors-related data included: (1) obesity (body mass index (BMI) ≥30), (2) congestive heart failure (CHF) and ejection fraction (EF), (3) previous myocardial infarction (MI), (4) angina pectoris (AP), (5) previous myocardial revascularization procedures (percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG)), ( 6) hypertension (HT), (7) peripheral artery disease (PAD); ( 8) hyperlipoproteinemia (HLP), (9) diabetes mellitus (DM), (10) smoking, (11) previous vascular surgery, (12) presence of abdominal aortic aneurysm (AAA), and (13) family history of carotid stenosis.…”

“…3,5 Carotid endarterectomy (CEA) is a standard treatment for lowering the risk of stroke in patients with severe asymptomatic and symptomatic carotid stenosis. 2,6,7 It is still somewhat controversial as to which surgical technique should be preferred, but eversion carotid endarterectomy (eCEA) has been reported to be a safe and feasible procedure in patients with significant carotid stenosis. [7][8][9][10] However, carotid artery stenting (CAS) has increasingly emerged as an alternative to eCEA in high-risk symptomatic and moderate-risk asymptomatic patients.…”

“…2,6,7 It is still somewhat controversial as to which surgical technique should be preferred, but eversion carotid endarterectomy (eCEA) has been reported to be a safe and feasible procedure in patients with significant carotid stenosis. [7][8][9][10] However, carotid artery stenting (CAS) has increasingly emerged as an alternative to eCEA in high-risk symptomatic and moderate-risk asymptomatic patients. 2,6,7 Carotid restenosis after CEA can occur as a result of neointimal hyperplasia in the early postoperative period (<2 years) or recurrent atherosclerotic lesions in the following period.…”

“…[7][8][9][10] However, carotid artery stenting (CAS) has increasingly emerged as an alternative to eCEA in high-risk symptomatic and moderate-risk asymptomatic patients. 2,6,7 Carotid restenosis after CEA can occur as a result of neointimal hyperplasia in the early postoperative period (<2 years) or recurrent atherosclerotic lesions in the following period. 6,11,12 Studies showed that in-stent restenosis after CAS varies between 5 and 21% with different follow-up periods, while after eCEA, carotid restenosis rates vary from 6 to 36%.…”

“…7-10 However, carotid artery stenting (CAS) has increasingly emerged as an alternative to eCEA in high-risk symptomatic and moderate-risk asymptomatic patients. 2,6,7…”