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.

European Stroke Organisation (ESO) guidelines on mobile stroke units for prehospital stroke management

“…60 The updated Cochrane Collaboration risk of bias tool (RoB 2) 61 was used for the risk of bias assessment, in line with previous ESO guidelines. 35,56,62 The assessment of the risk of bias in each study reporting data on excellent functional outcome (mRS 0–1 at 90 days; outcome allocated with the highest priority in our guideline manuscript) was summarised in a risk of bias chart (Supplemental Figure 1). The validity of the reported analyses was independently evaluated by all MWG members.7.…”

The Impact of Sex and Gender on Stroke

“…The most recent guidelines on the management of carotid artery stenosis recommend carotid endarterectomy in symptomatic patients with ≥50% stenosis and in asymptomatic patients with ≥60% stenosis. 147,148 Carotid artery stenting can be considered for symptomatic patients with stenosis of ≥50% at high risk for carotid endarterectomy for anatomic or medical reasons 147 or for patients <70 years old with symptomatic ≥50% carotid stenosis. 148 These recommendations warrant a review on the impact of sex on these surgical and endovascular treatments of carotid stenosis.…”

Neues in der Prävention des Schlaganfalls

“…Bei der Schlaganfallprophylaxe von Stenosen der A. carotis interna wird zwischen der Primärprävention und Sekundärprävention unterschieden. Für die operative Therapie von asymptomatischen Karotisstenosen gibt es 5 randomisierte Studien, wobei 2038 Patienten operiert und 2764 Patienten konservativ behandelt wurden [60]. Die zweite Studie zur Therapie asymptomatischer Karotisstenosen (ACST-2) fand keine Unterschiede in den Komplikationsraten und den vaskulären Ereignissen bei Patienten, die operiert wurden gegenüber Patienten, bei denen ein Karotisstenting erfolgte [61]…”

“…Bei Patienten mit einer symptomatischen Karotisstenose im Alter von unter 70 Jahren kann eine Endarteriektomie oder ein Karotisstenting durchgeführt werden 60 . Der therapeutische Nutzen der Operation oder des Stentings bei symptomatischen Patienten besteht allerdings nur, wenn das Schlaganfallrisiko und Mortalitätsrisiko unter 4 % liegen.…”