- 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.

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