European Stroke Organisation guideline on endarterectomy and stenting for carotid artery stenosis

Abstract

Atherosclerotic stenosis of the internal carotid artery is an important cause of stroke. The aim of this guideline is to analyse the evidence pertaining to medical, surgical and endovascular treatment of patients with carotid stenosis. These guidelines were developed based on the ESO standard operating procedure and followed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. The working group identified relevant questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and wrote recommendations. Based on moderate quality evidence, we recommend carotid endarterectomy (CEA) in patients with ≥60–99% asymptomatic carotid stenosis considered to be at increased risk of stroke on best medical treatment (BMT) alone. We also recommend CEA for patients with ≥70–99% symptomatic stenosis, and we suggest CEA for patients with 50–69% symptomatic stenosis. Based on high quality evidence, we recommend CEA should be performed early, ideally within two weeks of the last retinal or cerebral ischaemic event in patients with ≥50–99% symptomatic stenosis. Based on low quality evidence, carotid artery stenting (CAS) may be considered in patients < 70 years old with symptomatic ≥50–99% carotid stenosis. Several randomised trials supporting these recommendations were started decades ago, and BMT, CEA and CAS have evolved since. The results of another large trial comparing outcomes after CAS versus CEA in patients with asymptomatic stenosis are anticipated in the near future. Further trials are needed to reassess the benefits of carotid revascularisation in combination with modern BMT in subgroups of patients with carotid stenosis.

Non-stenotic Carotid Plaques in Embolic Stroke of Unknown Source

“…This explains the benefit of various antiinflammatory drugs (e.g., canakinumab, colchicine) for the prevention of atherosclerotic cardiovascular diseases (86,87,143). In patients with ESUS and ipsilateral non-stenotic carotid plaque, the effect of anti-inflammatory agents is worth exploring, especially in those with high-risk plaque features since they would not be offered revascularization procedures as first-line treatment according to current guidelines (144)(145)(146). Data from the ongoing Colchicine for Prevention of Vascular Inflammation in Non-Cardioembolic Stroke (CONVINCE, NCT02898610) might answer the question of whether patients with ESUS with or without ipsilateral non-stenotic carotid plaques would benefit from the addition of low-dose colchicine to best medical therapy for secondary stroke prevention (147).…”

Can intracranial time-of-flight-MR angiography predict extracranial carotid artery stenosis?

“…While their standard of comparison was DSA, we used US as suggested by the European Stroke Organization (ESO) [17]. Moreover, they focused on stenoses grades of 80% or higher, whereas we included patients with ≥ 50% stenosis grade, as these patients-if symptomatic-benefit from carotid endarterectomy according to the guidelines of the ESO [18].…”

Extra-Cranial Carotid Artery Stenosis: An Objective Analysis of the Available Evidence

“…We are performing an updated critical comparative audit of guidelines regarding carotid "revascularization" procedures. Unfortunately, the procedural biases mentioned above are still common, including in the most recently published guidelines (145)(146)(147). At least with respect to asymptomatic carotid stenosis patients, guidelines from Australia and Denmark discourage CEA and CAS or screening (148)(149)(150).…”