Best practice in asymptomatic carotid stenosis
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- Clinical trials have shown that carotid endarterectomy (CEA) reduces the risk of stroke compared to best medical treatment (BMT) alone in patients with asymptomatic carotid stenosis over 50%-60%. - However, more recent evidence suggests the risk of stroke for asymptomatic patients on BMT alone has declined over time and is now under 1% annually. Intensive medical management may further reduce stroke risks. - While CEA remains an option for very high-risk asymptomatic patients, the marginal benefit is small and BMT alone may now be preferred for most asymptomatic carotid stenosis cases given the low stroke risks with improved medical therapy.
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Best practice in asymptomatic carotid stenosis
- 1. Best practice in asymptomaticcarotid stenosis Dr. Pascual Lozano Vilardell Angiología y Cirugía Vascular
- 2. BEST PRACTICE FOR ASYMPTOMATIC CAROTID STENOSIS Clinical trials 30 days risk CEA ACAS 2,3% ACST 2,8% ACAS. Endarterectomy for asymptomatic carotid artery stenosis. JAMA 1995;273:1421-1428 Halliday A et al. Prevention of disabling and fatal strokes by successful CEA in patients without recent neurologic symptoms: a randomised controlled trial. Lancet 2004;363:1491-1502
- 3. BEST PRACTICE FOR ASYMPTOMATIC CAROTID STENOSIS Clinical trials 5 year risk CEA BMT RRR NNT ACAS 5,1% 11,0% 54% 84 ACST 6,4% 11,8% 46% 70 10 year risk ACST 13,4% 17,9% 26% ACAS. Endarterectomy for asymptomatic carotid artery stenosis. JAMA 1995;273:1421-1428 Halliday A et al. Prevention of disabling and fatal strokes by successful CEA in patients without recent neurologic symptoms: a randomised controlled trial. Lancet 2004;363:1491-1502 Halliday A, et al. 10-year stroke prevention after successful CEA for asymptomatic carotid stenosis (ACST-1): a multicenter randomised trial. Lancet 2010;376:1074-1084
- 4. BEST PRACTICE FOR ASYMPTOMATIC CAROTID STENOSIS ESVS, SVS, AHA… Carotid endarterectomy is indicated in all patients with asymptomatic carotid stenosis > 60%, if periprocedural rate of death-stroke is < 3%
- 5. BEST PRACTICE FOR ASYMPTOMATIC CAROTID STENOSIS CREST results in asymptomatic CREST ASYMPTOMATIC periprocedural 4 years CEA 1,4% 2,7% CAS 2,5% 4,5% Death-stroke. MI excluded Brott et al. Stenting versus endarterectomy for treatment of carotid artery stenosis. N Eng J Med 2010;363:11-13
- 6. BEST PRACTICE FOR ASYMPTOMATIC CAROTID STENOSIS CREST results in asymptomatic SVS REGISTRY CEA 2,0 % CAS 4,6 % Combined death-stroke-MI Giles KA et al. Stroke and death after CEA and CAS with and without high risk criteria. J VascSurg 2010;52:1497-1504
- 7. BEST PRACTICE FOR ASYMPTOMATIC CAROTID STENOSIS 2008 survey Klein A et al. Management of carotid stenosis- polling results. N Eng J Med 2008,358:e23
- 8. BEST PRACTICE FOR ASYMPTOMATIC CAROTID STENOSIS Concerns about revascularization
- 9. BEST PRACTICE FOR ASYMPTOMATIC CAROTID STENOSIS Concerns about revascularization Marginal surgical benefit (annual ARR 1%) Patient selection Nature of interventions Results “in the real world” Reporting methods Emerging rol of CAS Increased evidence risk of stroke is declining with the improvement of BMT Abbott AL. Medical intervention alone is now best for prevention of stroke associated with asymptomatic severe carotid stenosis. A systematic review. Stroke 2009;573-83
- 10. BEST PRACTICE FOR ASYMPTOMATIC CAROTID STENOSIS Recurrent stroke rate 1960-2010 8,71% 4,04% Hong K et al. Declining Stroke and Vascular Events Recurrence Rates in Secondary Prevention Trials. Circulation 2011;123:2111-2119
- 11. BEST PRACTICE FOR ASYMPTOMATIC CAROTID STENOSIS Recurrent stroke rate 1960-2010 Declining of event rates per decade Recurrent stroke 1,0 % Fatal stroke 0,3 % Major vascular events 1,3% Hong K et al. Declining Stroke and Vascular Events Recurrence Rates in Secondary Prevention Trials. Circulation 2011;123:2111-2119
- 12. BEST PRACTICE FOR ASYMPTOMATIC CAROTID STENOSIS Stroke rates in asymptomatic 1985-2007 Stroke type time Decrease Ipsilateral stroke 1985-2007 1,7% Ipsilateral stroke/TIA 1985-2005 7% Abbott AL. Medical intervention alone is now best for prevention of stroke associated with asymptomatic severe carotid stenosis. Stroke 2009;40:573-583
- 13. BEST PRACTICE FOR ASYMPTOMATIC CAROTID STENOSIS Stroke rates in asymptomatic 1985-2007 ipsilateral stroke any stroke Abbott AL. Medical intervention alone is now best for prevention of stroke associated with asymptomatic severe carotid stenosis. Stroke 2009;40:573-583
- 14. BEST PRACTICE FOR ASYMPTOMATIC CAROTID STENOSIS Stroke rates in medical arm ACAS and ACST 1985-2010 3,5% 2,4% 1,4% 2,2% 1,1% 0,7% Naylor AR. What is the current status of invasive treatment of extracraneal carotid artery disease? Stroke 2011;42:2080-85
- 15. BEST PRACTICE FOR ASYMPTOMATIC CAROTID STENOSIS Rate of stroke in asymptomatics OXFORD VASCULAR STUDY (2002-2009) 101 patients with ACS BMT Annual ipsilateral stroke rate 0,34% Marquardt L et al. Low risk of ipsilateral stroke in patients with ACS on best medical treatment. Stroke 2010;41:11-17
- 16. BEST PRACTICE FOR ASYMPTOMATIC CAROTID STENOSIS Embolic signals and stroke Presence of MES are related to risk of stroke 90% no MES AAR <1% 10% with MES AAR 15% Spence JD et al. Absence of MES on TCD identifies low-risk patients with Asymptomatic Carotid Stenosis. Stroke 2005;36:2373-2378
- 17. BEST PRACTICE FOR ASYMPTOMATIC CAROTID STENOSIS Embolic signals and stroke ACES (Asymptomatic Carotid Emboli Study) Prospective multicenter study Objective: to detect MES by TCD Endpoints: TIA or ipsilateral stroke Hypothesis: MES predicts ipsilateral TIA or stroke Markus HS et al. Asymptomatic embolisation for prediction of stroke in the ACES: a prospective observational study. Lancet Neurol 2010;9:663-671
- 18. BEST PRACTICE FOR ASYMPTOMATIC CAROTID STENOSIS Embolic signals and stroke Patients with MES Mean number MES Baseline 1 10% 2,63 (1-20) Baseline 2 11% 2,23 (1-11) Markus HS et al. Asymptomatic embolisation for prediction of stroke in the ACES: a prospective observational study. Lancet Neurol 2010;9:663-671
- 19. BEST PRACTICE FOR ASYMPTOMATIC CAROTID STENOSIS Embolic signals and stroke 32 primary endpoints: 26 TIA, 6 strokes AAR ipsilateral stroke MES 3,62% No MES 0,70% HR 2,54 (95%CI 1,20-5,36) Markus HS et al. Asymptomatic embolisation for prediction of stroke in the ACES: a prospective observational study. Lancet Neurol 2010;9:663-671
- 20. BEST PRACTICE FOR ASYMPTOMATIC CAROTID STENOSIS Embolic signals and stroke 468 patients 199 (2000-2002) 269 (2003-2007) Intensive medical therapy Spence JD et al. Effects of Intensive Medical Therapy on Microemboli and Cardiovascular Risk in ACS. Arch Neurol 2010;67:180-86
- 21. BEST PRACTICE FOR ASYMPTOMATIC CAROTID STENOSIS Embolic signals and stroke Patients with MES Carotid plaque Cardiovascular events 2000-2002 12,6% 69 mm2 17,6% 2003-2007 3,7% 23 mm2 5,6% Spence JD et al. Effects of Intensive Medical Therapy on Microemboli and Cardiovascular Risk in ACS. Arch Neurol 2010;67:180-86
- 22. CONCLUSIONS In patients with asymptomatic carotid stenosis Risk of stroke is declining over time Medical treatment has improved Annual risk of stroke on BMT < 1%
- 23. CONCLUSIONS In patients with asymptomatic carotid stenosis There is a subgroup at high risk of stroke Wemustidentifythissubgroup
- 24. PREDICTION OF STROKE IN ACS Embolic signals on TCD Cerebrovascular reserve Plaque morphology Stenosis progresion rate Serum biomarkers
- 25. CONCLUSIONS In patients with asymptomatic carotid stenosis However, we don’t have level IA evidence of this afirmations We need clinical trials