Update on Extracranial Carotid Stenosis

Abstract

Carotid stenosis is a risk factor of ischaemic stroke and has an increasing prevalence with age. Stroke risk under optimised medical therapy, as well as recommendations of carotid artery endarterectomy/stenting, as therapy in high risk carotid stenosis, are discussed in consideration of recent research results. KeywordsCarotid artery stenosis, carotid endarterectomy, angioplasty and stenting, optimal medical treatment, stroke prevention.Disclosure: Tilman Reiff, Christoph Gumbinger and Sibu Mundiyanapurath have nothing to disclose in relation to this paper. Peter A Ringleb is a member of the steering committee of SPACE-2. This article is a short opinion piece and has not been submitted to external peer reviewers. No funding was received for the publication of this article.Open Access: This article is published under the Creative Commons Attribution Noncommercial License, which permits any non-commercial use, distribution, adaptation and reproduction provided the original author(s) and source are given appropriate credit. 1,2 The prevalence of atherosclerotic carotid disease increases with age. Epidemiological data show a prevalence of 3.1% for men and 0.9% for women in individuals with ≥70% North American Symptomatic Carotid Endarterectomy Trial (NASCET) criteria carotid stenosis who were 80 years or older. For ≥50% carotid stenosis, prevalence is 7.5% for men and 5.0% for women.3 A pooled analysis of the general population indicates a prevalence of ≥70% carotid stenosis of 1.7% (95% confidence interval [CI] 0.7-3.9%).4 Due to improvements in medical therapy, the annual ipsilateral stroke risk of asymptomatic carotid stenosis ≥50% has decreased within the last decades from about 2% to 0.5-1.0%. [5][6][7] Data are inconsistent as to whether the grade of stenosis (>70-99%) increases stroke risk.8-10 Risk of recurrent stroke in recently symptomatic carotid stenosis is reported with 6% in the first month and about 20% within the first year.11 Other data show a higher risk (21% in the first two weeks and 32% within 12 weeks).12 More recent studies indicate a high risk (6-21%) of recurrent stroke in the first 72 hours after initial stroke symptoms, but a lower risk of 11.5% at 14 days, and 18.8% at 90 days. 10,13,14 Quite low rates of recurrent stroke were seen under aggressive medical therapy with acetylsalicylic acid, clopidogrel and simvastatin (2.5% within 90 days). 15Carotid atherosclerosis is also a marker for high risk of myocardial infarction and vascular death.16 Considering all these facts, patients with carotid stenosis should receive intensive medical therapy with statins and antiplatelets; treatment of hypertension and diabetes; they should follow a healthy diet, and perform lifestyle modifications. [17][18] Discussions about invasive treatment of asymptomatic carotid stenosis are currently controversial. The recently published Asymptomatic Carotid Surgery Trial-1 (ACT-1) study confirmed that carotid artery stenting (CAS) was non-inferior to carotid endarterectomy (CEA) in a cohort of 1,453 patien...