Natural History of Non-operative Management in Asymptomatic Patients with 70%–80% Internal Carotid Artery Stenosis by Duplex Criteria

Abstract

WHAT THIS PAPER ADDSIn this single institution retrospective analysis of patients with asymptomatic internal carotid artery stenosis identified on duplex ultrasound as moderate to severe (70%e80%) from 2003 to 2018. There was a low rate (5.3%) of stroke/transient ischaemic attack without documented progression of stenosis, but there was a high rate (24.1%) of stenosis progression, as well as a 16.3% mortality rate at five years. The data reinforce the need to follow these patients closely, and patients at a higher risk of death, in particular, may benefit the least from intervention.Objective: Treatment of asymptomatic internal carotid artery (ICA) stenosis, particularly for moderate to severe (70%e80%) disease, is controversial. The goal was to assess the clinical course of patients with moderate to severe carotid stenosis. Methods: A single institution retrospective analysis of patients with asymptomatic ICA stenosis identified on duplex ultrasound as moderate to severe (70%e80%) from 2003 to 2018 were analysed. Duplex criteria for 70%e80% stenosis was a systolic velocity of !325 cm/s or an ICA:common carotid artery ratio of !4, and an end diastolic velocity of <140 cm/s. Asymptomatic status was defined as no stroke/transient ischaemic attack (TIA) within six months of index duplex. Primary outcomes were progression of stenosis to >80%, ipsilateral stroke/TIA without documented progression, and death. Results: In total, 206 carotid arteries were identified in 182 patients meeting the inclusion criteria. Mean patient age was 71.5 years, 57.7% were male, and 67% were white. There were 19 stenoses removed from analysis except for survival analysis as they initially underwent carotid endarterectomy or carotid artery stent based on surgeon/patient preference. Documented progression occurred in 24.1% of stenoses. There were 5.3% of stenoses associated with an ipsilateral stroke/TIA without documented progression, which occurred at a mean of 26.4 months. KaplaneMeier analysis demonstrated a 60.3% five year freedom from stenosis progression, 92.5% five year freedom from stroke/TIA without documented progression, and 83.7% five year survival. Risk factors associated with stroke/TIA without documented progression at five years were atrial fibrillation (hazard ratio [HR] 14.87, 95% confidence interval [CI] 2.72e81.16; p ¼ .002) and clopidogrel use at index duplex (HR 6.19, 95% CI 1.33e28.83; p ¼ .020). Risk factors associated with death at five years were end stage renal disease (HR 9.67, 95% CI 2.05e45.6; p ¼ .004), atrial fibrillation (HR 7.55, 95% CI 2.48e23; p < .001), prior head/neck radiation (HR 6.37, 95% CI 1.39e29.31; p ¼ .017), non-obese patients (HR 5.49, 95% CI 1.52e20; p ¼ .009), and non-aspirin use at index duplex (HR 3.05, 95% CI 1.12e8.33; p ¼ .030). Conclusion: Patients with asymptomatic moderate to severe carotid stenosis had a low rate of stroke/TIA without documented progression. However, there was a high rate of stenosis progression reinforcing the need to follow these patients closely.

Temporal Trends and Determinants of Stroke Risk in Patients With Medically Treated Asymptomatic Carotid Stenosis

“…After screening of 5915 unique reports and assessing the full texts of 231 for eligibility, we included 73 studies reporting 28 625 patients with ≥50% ACAS (Figure 1; Table S2). 8–10,16–85…”

Riesgo de accidente cerebrovascular en pacientes con aterosclerosis carotídea asintomática: ¿se debe tratar médicamente o quirúrgicamente?

“…En los últimos 10 años, se han llevado a cabo estudios que han permitido conocer la historia natural de la enfermedad del paciente con aterosclerosis y estenosis carotídea asintomática, manejados con tratamiento médico (37)(38)(39)(40)(41) . Cheng et al (37) realizaron un análisis retrospectivo de 206 carótidas con estenosis asintomática del 70 %-80 %, donde se observó que, durante una ventana de tiempo de 15 años, aproximadamente, se encontró progresión en el 24 % de estas, y que hubo una incidencia de ictus del 5,3 %. Dentro de los factores de riesgo reportados para el ictus sin progresión 33).…”

“…Dentro de los factores de riesgo reportados para el ictus sin progresión 33). Por tanto, los autores de este estudio concluyeron que se evidenció una alta frecuencia de progresión de estenosis, pero baja en ictus (37) .…”

Carotid atherosclerotic disease: A systematic review of pathogenesis and management

“…In terms of the natural history of asymptomatic higher grade, i.e., >70% stenosis, Cheng et al . [ 74 ] reported that the 5-year risk of stroke or TIA associated with ipsilateral stenosis was 5.3%. This study was based upon serial carotid duplex scan with a progression rate of stenosis, over time, of 24.1%.…”