Updated Society for Vascular Surgery guidelines for management of extracranial carotid disease: Executive summary

Abstract

In 2008, the Society for Vascular Surgery published guidelines for the treatment of carotid bifurcation stenosis. Since that time, a number of prospective randomized trials have been completed and have shed additional light on the best treatment of extracranial carotid disease. This has prompted the Society for Vascular Surgery to form a committee to update and expand guidelines in this area. The review was done using the GRADE methodology.[corrected] The perioperative risk of stroke and death in asymptomatic patients must be below 3% to ensure benefit for the patient. Carotid artery stenting (CAS) should be reserved for symptomatic patients with stenosis 50% to 99% at high risk for CEA for anatomic or medical reasons. CAS is not recommended for asymptomatic patients at this time. Asymptomatic patients at high risk for intervention or with <3 years life expectancy should be considered for medical management as first line therapy. In this Executive Summary, we only outline the specifics of the recommendations made in the six areas evaluated. The full text of these guidelines can be found on the on-line version of the Journal of Vascular Surgery at http://journals.elsevierhealth.com/periodicals/ymva.

The American Academy of Neurology's Top Five Choosing Wisely recommendations

“…Based on studies reporting an upfront surgical complication rate ranging from 2.3% 33 to 3.1% 34 among patients undergoing CEA for asymptomatic stenosis of .60%, and an absolute risk reduction for stroke or death of roughly 5% to 6% in the surgical group at 5 years, several medical specialty societies [35][36][37][38] have recommended that surgery for asymptomatic patients be reserved for those with a perioperative complication risk of ,3% and a life expectancy of greater than 3 to 5 years. Although recent studies have reported lower stroke rates with improvements in both surgical 36 and medical management, 39 no recent randomized trials have compared these treatments.…”

Systematic Review of Guidelines for the Management of Asymptomatic and Symptomatic Carotid Stenosis

“…Two guidelines 41,46,47 cited the Stenting and Angioplasty With Protection in Patients at High Risk for Endarterectomy Trial (SAPPHIRE) 79 for defining high-CEA-risk clinical scenarios. Twenty-nine guidelines included specific recommendations for the use of CAS for patients with high-CEA-risk ACS 28,31,32,[35][36][37][38]41,[43][44][45][46][47][55][56][57][58]62,63 or SCS,27,28,[31][32][33][34][35][36][38][39][40][41][42][44][45][46][47][48][49][50][51][52][53][54][55][56]58,[61]…”

“…[36][37][38][39]42,48,49,[54][55][56][57]62,63 In the other 17 guidelines, the cause of high-CEA-risk was characterized as being because of only reasons related to vascular anatomy and in others as being because of vascular anatomy or medical comorbidities. Nine of these guidelines gave no specific examples of high-CEArisk scenarios [42][43][44][45]48,49,54,57,63 or referred to other guidelines. …”

“…Nine of these guidelines gave no specific examples of high-CEArisk scenarios [42][43][44][45]48,49,54,57,63 or referred to other guidelines.…”

Carotid stent guidelines: How the society for vascular surgery (SVS) “had its cake and ate it too”

“…The document was long awaited, and was purposefully delayed until February 2011, in order to be able to consider the most recent data from the largest randomized clinical trial, Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) [2]. In September 2011, the Society for Vascular Surgery (SVS), which had endorsed the broad-based multispecialty guideline in February 2011, published a contradictory guideline [3]. The SVS guideline reneged on the compromise recommendations made several months before, which had been endorsed by the SVS leadership.…”