The Society for Vascular Surgery implementation document for management of extracranial cerebrovascular disease

Optimal Management of Asymptomatic Carotid Stenosis in 2021: The Jury is Still Out. An International, Multispecialty, Expert Review and Position Statement

“…Although progress has been made in certain areas, controversy in other areas will persist. The most recent guidelines, namely the 2021 SVS, 5 the 2021 European stroke organisation 18 and the 2020 German-Austrian guidelines 17 still recommend CEA plus BMT instead of BMT alone in patients with 60% 17,18 or > 70% ACS 5 at low surgical risk and a reasonable life-expectancy for the long-term prevention of stroke/death. It is now clear that all ACS patients do not have the same stroke risk 36,38,39 and therefore the management of patients with ACS may need to be individualized based on specific imaging/clinical criteria, 4.17 as well as individual patient preferences/ needs.…”

“…17 In addition, these guidelines specifically recommended that periprocedural stroke/death rates should be as low as possible for CEA/CAS and should not exceed 2%. 17 This lower threshold for complications (< 2% 17 instead of the previously quoted < 3%) 4,5,11,12 is a recognition of the lower current perioperative stroke/death rates following CEA/CAS compared with those of the landmark RCTs. 19À21 The controversial issue of screening for ACS Each year in the United States about 795,000 patients suffer a stroke.…”

“…The SVS recently released its updated guidelines on the management of patients with asymptomatic and symptomatic carotid stenosis. 5 The 2021 SVS Guidelines provided a strong recommendation for CEA plus BMT over BMT alone for "low surgical risk patients" with > 70% ACS provided perioperative stroke/death rates are < 3% and the patient has a life expectancy of > 5 years (Level of recommendation: Grade 1 [Strong]; Quality of evidence: B [Moderate]). 5 The 2021 European stroke organization (ESO) guidelines reported that there is moderate quality evidence that CEA reduces the long-term risk of ipsilateral stroke, including periprocedural stroke in any territory or periprocedural death compared with BMT alone (RR: 0.73, 95% CI: 0.59À0.90; equivalent to 19 fewer events with CEA per 1000).…”

“…5 The 2021 SVS Guidelines provided a strong recommendation for CEA plus BMT over BMT alone for "low surgical risk patients" with > 70% ACS provided perioperative stroke/death rates are < 3% and the patient has a life expectancy of > 5 years (Level of recommendation: Grade 1 [Strong]; Quality of evidence: B [Moderate]). 5 The 2021 European stroke organization (ESO) guidelines reported that there is moderate quality evidence that CEA reduces the long-term risk of ipsilateral stroke, including periprocedural stroke in any territory or periprocedural death compared with BMT alone (RR: 0.73, 95% CI: 0.59À0.90; equivalent to 19 fewer events with CEA per 1000). 18 Consequently, these guidelines recommended CEA in patients with 60% ACS considered to be at increased risk of stroke on BMT alone (Quality of evidence: moderate; strength of recommendation: strong for CEA).…”

“…1À3 Carotid endarterectomy (CEA) is currently strongly recommended for patients with a 70À99% carotid stenosis within 14 days of a TIA/ minor ischemic stroke episode in order to remove the "unstable" atherosclerotic carotid plaque (which is the source of the thromboemboli) and, consequently, to reduce the risk of recurrent stroke/death (Class I; Level of evidence: A). 4,5 In contrast to symptomatic carotid stenosis, the optimal management of asymptomatic carotid stenosis (ACS) is enduringly controversial. Each year there are about 800,000 strokes in the United States 6 and approximately 1,400,000 strokes in Europe.…”