Modern medical treatment with or without carotid endarterectomy for severe asymptomatic carotid atherosclerosis

Kolos, I P; Troitskiy, A. V.; Балахонова, Т. В.; Shariya, M.A.; Skrypnik, Denis; Tvorogova, T. V.; Деев, А. Д.; Boytsov, S. А.; Akezheva, Lana R.; Dupik, Nikolay V.; Ершова, А. И.; Федотенков, И. С.; Fyodorova, Vera I.; Khabazov, Robert I.; Lukyanov, М. М.; Nikonova, Mariya; Shevchenko, Nataliia; Stepanyants, Ekaterina Yu.; Strazden, E. Yu.; Tripoten, M.; Ust'yantseva, Nataliya V.

doi:10.1016/j.jvs.2015.05.005

Cited by 21 publications

(13 citation statements)

References 27 publications

(19 reference statements)

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“…The Aggressive Medical Treatment Evaluation for Asymptomatic Carotid Artery Stenosis (AMTEC) study randomised 55 patients with 70–79% carotid stenosis to receive CEA ( n = 31) or medical therapy alone ( n = 24) between 2009 and 2013. 20 Stenosis was graded by ultrasound examinations, but had to be confirmed by computed tomographic or magnetic resonance angiography (CTA/MRA) or catheter angiography. The trial was stopped prematurely by the independent data and safety monitoring board because of a high rate of the primary endpoint in the medical arm after a median follow-up period of 3.3 years (maximum, 5.0 years); results were reported in 2015.…”

Section: Resultsmentioning

confidence: 99%

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

Bonati

Kakkos

Berkefeld

et al. 2021

European Stroke Journal

155

110

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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.

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Section: Resultsmentioning

confidence: 99%

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

Bonati

Kakkos

Berkefeld

et al. 2021

European Stroke Journal

155

110

View full text Add to dashboard Cite

show abstract

“…The SPACE-2 trial (n = 316) reported no significant difference in composite outcome of stroke or death (30 days) or ipsilateral ischemic stroke (1 year) after carotid endarterectomy (unadjusted hazard ratio [HR], 2.82 [95% CI, 0.33-24.07]) or carotid artery stenting (unadjusted HR, 3.50 [95% CI, 0.42-29.11]) compared with best medical therapy at 1 year. The smaller AMTEC trial (n = 55) reported a statistically significantly lower composite risk of nonfatal ipsilateral stroke or death among the carotid endarterectomy group at a median of 3.3 years (calculated unadjusted HR, 0.20 [95% CI, 0.06-0.65]). The 2 trials, 2 national data sets, and 3 surgical registries reported procedural harms associated with carotid endarterectomy (n = 1 903 761) or carotid artery stenting (n = 332 103) (KQ4).…”

Section: Resultsmentioning

confidence: 99%

Screening for Asymptomatic Carotid Artery Stenosis in the General Population

Webber

Coppola

2021

JAMA

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Carotid artery stenosis is a known stroke risk factor and a cardiovascular disease marker. No population-based screening trials for carotid artery stenosis have been conducted. Optimal treatment for clinically significant asymptomatic carotid artery stenosis remains uncertain. Options include best medical therapy alone or in combination with revascularization (carotid endarterectomy or carotid artery stenting) to prevent stroke. Revascularization has been associated with small longterm benefits compared with best medical therapy alone in historic trials but can result in surgical harms. 1 Since 2007, the US Preventive Services Task Force (USPSTF) has maintained a D recommendation against screening for asymptomatic carotid artery stenosis in the general adult population. This recommendation was based on a low prevalence of stroke attributable to asymptomatic carotid artery stenosis in the general population, the small benefit of surgery compared with medical therapy in older trials, and the potential for small to moderate surgical harms. This brief evidence update aimed to identify studies published since the previous 2014 review 1 to inform an updated USPSTF recommendation.

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“…The aggressive medical treatment evaluation for asymptomatic carotid artery stenosis (AMTEC) study was the first randomized controlled trial comparing CEA and modern medical treatment (aggressive lipid-lowering and antihypertensive medication, and aspirin). However, the trial was stopped after a median follow-up of 3.3 years because of the obvious superiority of CEA (71). CREST 2 and SPACE-2 are now ongoing, and will compare intensive medical management alone versus CEA plus intensive medical management or CAS plus intensive medical management in patients who are asymptomatic (72–74).…”

Section: Best Medical Treatment Versus Carotid Revascularizationmentioning

confidence: 99%

Factors Influencing Decision Making for Carotid Endarterectomy versus Stenting in the Very Elderly

Heo

Bushnell

2017

Front. Neurol.

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As the population ages worldwide, the number of elderly patients with carotid stenosis is also increasing. There have been many large clinical trials comparing carotid endarterectomy (CAE) versus stenting, but the inclusion criteria (i.e., symptomatic or asymptomatic), stenting methods (i.e., protection device), and primary end point (i.e., the definition of myocardial infarction and follow-up period) were different between trials. Therefore, the interpretation of those results is difficult and requires attention. When it comes to age, the patients older than 80 years were excluded or stratified to a high risk group in previous landmark trials. However, a recent guideline recommended that endarterectomy may be associated with lower stroke risk compared with carotid artery stenting in patients older than 70 years with symptomatic carotid disease. The annual risk of stroke in individuals with asymptomatic carotid stenosis is about 1–3% but the risk is about 4–12% with symptomatic stenosis without carotid intervention. Although the outcome of CAE is better than that of carotid stenting in patients older than 70 years, the perioperative risk is higher in older patients. Therefore, it is important to classify high risk patients and consider underlying disability and life expectancy of very elderly patients before deciding whether to undergo a carotid intervention. In addition, we should also consider that the stroke rate with intensive medical treatment is unknown and is currently being investigated in randomized controlled trials. Intensive medical treatment includes high intensity statins, diabetes and blood pressure control, and aggressive antiplatelet treatment. The aim of this review is to report the factors that may be responsible for the variability in the treatment of carotid stenosis, particularly in the elderly population. This will allow the readers to integrate the current available evidence to individualize the treatment of carotid stenosis in this challenging population.

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Modern medical treatment with or without carotid endarterectomy for severe asymptomatic carotid atherosclerosis

Abstract: CEA as an initial management strategy could reduce the risk of death and major cerebrovascular events when added to MMT.

Cited by 21 publications

References 27 publications

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

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

Screening for Asymptomatic Carotid Artery Stenosis in the General Population

Factors Influencing Decision Making for Carotid Endarterectomy versus Stenting in the Very Elderly

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