Testing for asymptomatic carotid disease in patients with arterial disease elsewhere

Editor's Choice – Management of Atherosclerotic Carotid and Vertebral Artery Disease: 2017 Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS)

“…If all patients with a 70e 99% stenosis then underwent CEA, this would prevent about 230 strokes annually in the UK, which represents only 0.2% of the annual UK stroke burden. 74 In practice, 143 claudicants would need to be screened to identify 20 with a 70e99% stenosis for CEA, to prevent one stroke at 10 years. This would cost £76,000 (V88,300) per stroke prevented.…”

“…This would cost £76,000 (V88,300) per stroke prevented. 74 USPSTF recommends against screening for ACS 64 on the basis that RCTs may have overestimated benefits and used highly selected surgeons, while DUS screening (even with MRA corroboration) might lead to a large number of false positive patients being diagnosed as having a significant ACS. They also noted that medical therapy in the RCTs was outdated (Section 2.2.3.1.4), stroke rates have probably declined over recent decades and 'real world' stroke risks may have been under-reported.…”

Why do guidelines recommend screening for abdominal aortic aneurysms, but not for asymptomatic carotid stenosis? A plea for a randomized controlled trial

“…There are several reasons to support testing asymptomatic patients, among others: i) to monitor medical management, ii) to quantify ipsilateral stroke rates on BMT, iii) to validate new technologies to identify vulnerable plaques, and, iv) to randomize patients into interventional trials [41]. The main benefits of carotid screening would be to improve targeted plaque stabilizing/plaque removing therapies and to identify patients for randomization into trials.…”

Why is the management of asymptomatic carotid disease so controversial?

“…38 According to Thapar, there are five reasons for undertaking screening for the presence of asymptomatic carotid disease: (i) to select patients for revascularisation; (ii) to monitor risk factor control and medical therapy; (iii) to quantify ipsilateral stroke rates whilst on BMT; (iv) to validate new technologies for identifying the vulnerable plaque and (v) for randomising patients within trials. 39 The USPSTF has just updated its 2007 recommendation and concluded that; "there are still no eligible studies that provide direct evidence that screening for ACS reduces fatal or non-fatal stroke" and they continue to recommend against routine and selective carotid screening. 37 Somewhat controversial was the USPSTF evaluation of the role of Duplex ultrasound as a potential screening tool for identifying patients with significant, asymptomatic carotid disease.…”