Management of carotid stenosis for primary and secondary prevention of stroke: state-of-the-art 2020: a critical review

Abstract

Carotid atherosclerotic plaque is encountered frequently in patients at high cardiovascular risk, especially in the elderly. When plaque reaches 50% of carotid lumen, it induces haemodynamically significant carotid stenosis, for which management is currently at a turning point. Improved control of blood pressure, smoking ban campaigns, and the widespread use of statins have reduced the risk of cerebral infarction to <1% per year. However, about 15% of strokes are still secondary to a carotid stenosis, which can potentially be detected by effective imaging techniques. For symptomatic carotid stenosis, current ESC guidelines put a threshold of 70% for formal indication for revascularization. A revascularization should be discussed for symptomatic stenosis over 50% and for asymptomatic carotid stenosis over 60%. This evaluation should be performed by ultrasound as a first-line examination. As a complement, computed tomography angiography (CTA) and/or magnetic resonance angiography are recommended for evaluating the extent and severity of extracranial carotid stenosis. In perspective, new high-risk markers are currently being developed using markers of plaque neovascularization, plaque inflammation, or plaque tissue stiffness. Medical management of patient with carotid stenosis is always warranted and applied to any patient with atheromatous lesions. Best medical therapy is based on cardiovascular risk factors correction, including lifestyle intervention and a pharmacological treatment. It is based on the tri-therapy strategy with antiplatelet, statins, and ACE inhibitors. The indications for carotid endarterectomy (CEA) and carotid artery stenting (CAS) are similar: for symptomatic patients (recent stroke or transient ischaemic attack ) if stenosis >50%; for asymptomatic patients: tight stenosis (>60%) and a perceived high long-term risk of stroke (determined mainly by imaging criteria). Choice of procedure may be influenced by anatomy (high stenosis, difficult CAS or CEA access, incomplete circle of Willis), prior illness or treatment (radiotherapy, other neck surgery), or patient risk (unable to lie flat, poor AHA assessment). In conclusion, neither systematic nor abandoned, the place of carotid revascularization must necessarily be limited to the plaques at highest risk, leaving a large place for optimized medical treatment as first line management. An evaluation of the value of performing endarterectomy on plaques considered to be at high risk is currently underway in the ACTRIS and CREST 2 studies. These studies, along with the next result of ACST-2 trial, will provide us a more precise strategy in case of carotid stenosis.

Acupuncture Combined with Traditional Chinese Medicine and Drug Therapy for the Treatment of Cerebral Infarction (Phlegm-Blood Stasis Syndrome) and Carotid Atherosclerotic Plaque: A Preliminary Randomized Controlled Study

“…Cerebral infarction (CI), also known as ischemic stroke, has been reported to rise at an annual rate of 8.7% in China [ 1 ]. However, economic development and measures such as improved blood pressure control, smoking ban campaigns, and widespread use of statins have significantly reduced the risk of fatality from 1984 to 2004 [ 1 – 3 ]. Atherosclerosis is a significant cause of IC.…”

Preoperative exercise training for adults undergoing elective major vascular surgery: A systematic review

“…Therefore, we do not think that revascularisation for carotid artery disease is a good model to explore the potential benefits of preoperative exercise in future research. This is not to say that other aspects of preoperative optimisation are not important (e.g., smoking cessation), and exercise may still have an important role as part of optimal medical management in patients with asymptomatic carotid stenosis [ 49 , 50 ] and in rehabilitation after stroke [ 51 ].…”

Successful implementation of best medical treatment for patients with asymptomatic carotid artery stenosis within a randomized controlled trial (SPACE-2)

“…However, even in this controlled trial setting, only approximately 75% of patients achieved sufficient adjustment of the required cholesterol levels. Meanwhile, since the start of the SPACE-2 trial in 2009, the cutoff values for LDL cholesterol were further reduced (< 100 mg/dl without CHD, < 70 mg/dl with CHD) [10] or even more strictly reduced to a target of 55 mg/dl and a reduction in LDL of > 50% of the initial value for patients in secondary cardiovascular prevention and for patients at very high risk [16]. Because of these stricter targets, recent guidelines recommend the use of more potent CSE inhibitors, the additional administration of ezetimibe, or even PCSK9 inhibitors [28].…”