Evidence-Based Carotid Interventions for Stroke Prevention: State-of-the-art Review

Abstract

Carotid artery stenosis is responsible for between 10–20% of all ischaemic strokes. Interventions, such as carotid end-arterectomy and carotid stenting, effectively reduce the risk of stroke in selected individuals. This review describes the history of carotid interventions, and summarises reliable evidence on the safety and efficacy of these interventions gained from large randomised clinical trials.Early trials comparing carotid endarterectomy to medical therapy alone in symptomatic patients, and asymptomatic patients, demonstrated that endarterectomy halved the risk of stroke and perioperative death in these two unique populations. The absolute risk reduction was smaller in the asymptomatic carotid trials, consistent with their lower absolute stroke risk. More recent trials in symptomatic patients, suggest that carotid stenting has similar long term durability to carotid endarterectomy, but possibly has higher procedural hazards dominated by non-disabling strokes. The Asymptomatic Carotid Surgery Trial-2, along with individual patient data meta-analysis of all asymptomatic trials, will provide reliable evidence for the choice of intervention in asymptomatic patients in whom a decision has been made for carotid revascularisation. Given improvements in effective cardiovascular medical therapy, in particular lipid-lowering medications, there is renewed uncertainty as to whether carotid interventions still provide meaningful net reductions in stroke risk in asymptomatic populations. Four large trials in Europe and the US are currently underway, and are expected to report longterm results in the next decade.It is essential that surgeons, interventionalists, and physicians continue to randomise large numbers of patients from around the world to clarify current uncertainty around the management of asymptomatic carotid stenosis.

Connectometry evaluation in patients undergoing carotid endarterectomy: an exploratory study

“…Atherosclerotic disease involving Internal Carotid Artery (ICA) is a well-known risk factor for ischemic stroke [1][2][3], but also the association between ICA disease and cognitive dysfunctions in patients without clinically evident cerebrovascular disease is well known [4]. In the past years, carotid artery revascularization (following Carotid Endarterectomy (CEA) or Carotid Artery Stenting (CAS)) demonstrated to be protective against occurrence of stroke in symptomatic and asymptomatic subjects [5,6].…”

Asymptomatic Carotid Stenosis: Intervention or Best Medical Therapy?

“…Ongoing RCTs such as the Carotid Revascularisation and Medical Management for Asymptomatic Carotid Stenosis trial (CREST-2) and the European Carotid Surgery Trial (ECST-2) will compare both CAS (with use of EPDs) and CEA with medical management in asymptomatic patients with severe carotid artery stenosis whilst the Endarterectomy Combined with Optimal Medical Therapy (OMT) versus OMT Alone in Patients With Asymptomatic Severe Atherosclerotic Carotid Artery Stenosis at Higher-than-average Risk of Ipsilateral Stroke (ACTRIS) trial will compare CEA, in conjunction with BMT, versus BMT alone [ 68 ••, 69 ••].…”

Safety of Stenting and Endarterectomy for Asymptomatic Carotid Artery Stenosis: A Meta-Analysis of Randomised Controlled Trials

“…The online MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases was searched from 1994 (when Morris et al 10 first deployed metal stents in two patients with carotid artery stenosis) to May 2017 for all RCTs that compared CAS with CEA for asymptomatic carotid stenosis. The following medical subject heading terms were used in Medline, and Emtree terms in Embase: carotid stenosis, stents, and carotid endarterectomy.…”