Stroke risk management in carotid atherosclerotic disease: a clinical consensus statement of the ESC Council on Stroke and the ESC Working Group on Aorta and Peripheral Vascular Diseases

Abstract

Carotid atherosclerotic disease continues to be an important cause of stroke, often disabling or fatal. Such strokes could be largely prevented through optimal medical therapy and carotid revascularization. Advancements in discovery research and imaging along with evidence from recent pharmacology and interventional clinical trials and registries and the progress in acute stroke management have markedly expanded knowledge base for clinical decisions in carotid stenosis. Nevertheless, there is variability in carotid-related stroke prevention and management strategies across medical specialities. Optimal patient care can be achieved by (1) establishing a unified knowledge foundation and (2) fostering multi-specialty collaborative guidelines. The emergent Neuro-Vascular Team concept, mirroring the multi-disciplinary Heart Team, embraces diverse specializations, tailores personalized, stratified medicine approaches to individual patient needs, and integrates innovative imaging and risk-assessment biomarkers. Proposed approach integrates collaboration of multiple specialists central to carotid artery stenosis management such as neurology, stroke medicine, cardiology, angiology, ophthalmology, vascular surgery, endovascular interventions, neuroradiology and neurosurgery. Moreover, patient education regarding current treatment options, their risks and advantages, is pivotal, promting patient’s active role in clinical care decisions. This enables optimization of interventions ranging from lifestyle modification, carotid revascularization by stenting or endarterectomy, as well as pharmacological management encompassing statins, novel lipid-lowering and antithrombotic strategies and targeting inflammation and vascular dysfunction. This consensus document provides a harmonized multi-specialty approach to multimorbidity prevention in carotid stenosis patients, based on comprehensive knowledge review, pinpointing research gaps in an evidence-based medicine approach. It aims to be a foundational tool for interdisciplinary collaboration and prioritized patient-centric decision-making.

Optimal Stroke Risk Management in Carotid Atherosclerotic Disease: A Patient-Centered Multidisciplinary Approach

“…6,7 These and other features of increased carotid-related risk of stroke are discussed in more detail in the Consensus document. 1 According to the 2023 ESVS Guidelines, 6 for AsxCS patients with clinical/imaging features associated with an increased risk of future stroke, carotid endarterectomy (CEA) should (Class IIa; Level of Evidence: B) and carotid artery stenting (CAS) may be considered (Class IIb; Level of Evidence: B), provided the patient’s life expectancy exceeds 5 years and 30-day stroke/death rates associated with the intervention are ≤3%. There is evidence suggesting that the management of AsxCS patients should be individualized, taking into consideration individual patient needs and characteristics, including life expectancy and comorbidities, ethnic, cultural and social characteristics, as well as personal preferences.…”

“…8 Stratification of future stroke risk and a patient-centered approach taking into consideration local expertise should therefore guide the management of AsxCS patients, as highlighted in the Consensus document, along with the evidence from the emerging RCTs and registries for the safety and efficacy of novel CAS technologies, such as improved intraprocedural cerebral protection (e.g., flow reversal, “mesh” stents) and post-procedural prevention of plaque-related embolism with “mesh” stents. 1,9…”

“…With several studies already published, and several more on-going, novel carotid stent technologies and improved intraprocedural cerebral protection may increase (“2 nd generation”) CAS applicability to SxCS. 1…”

“…A multispecialty Consensus statement recently released by the European Society of Cardiology (ESC) Council on Stroke and the ESC Working Group on Aorta and Peripheral Vascular Disease covers several key aspects of the diagnosis and management of carotid artery stenosis. 1 The expert panel included opinion leaders from different specialties that deliver primary and secondary care for patients with asymptomatic carotid stenosis (AsxCS) and carotid-related strokes. 1 This multispecialty participation minimized “surgical” versus “endovascular” versus “exclusively pharmacological” bias by defining a common knowledge base and delivering a balanced Consensus.…”

“…1 The expert panel included opinion leaders from different specialties that deliver primary and secondary care for patients with asymptomatic carotid stenosis (AsxCS) and carotid-related strokes. 1 This multispecialty participation minimized “surgical” versus “endovascular” versus “exclusively pharmacological” bias by defining a common knowledge base and delivering a balanced Consensus.…”