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We need to revise management 
guidelines of asymptomatic carotid 
atheroma 
Guy-André Pelouze MD 
Chirurgien des Hôpitaux 
Perpignan 
France
Asymptomatic carotid atheroma 
• Carotid: which means bifurcation and doesn’t 
mean main carotid, brachiocephalic, 
subclavian or vertebral arteries. 
• Atheroma: of the bifurcation which doesn’t 
mean restenosis, radiation-induced lesion, 
fibrodysplasia 
• Asymptomatic: which means no focal, 
ipsilateral neurological or ocular symptom 
during the past six months
The risk of stroke associated with asymptomatic 
atheroma of carotid bifurcation has fallen 
drastically 
• BMT (Statin/AP/ACE inhibitors) alone reduces the 
risk at least of 60-80% 
• Arteriography no longer mandatory in those 
patients, Duplex and angioCT don’t provoke 
stroke and provide more reliable imaging 
• Trials comparing CEA vs BMT had not taken in 
account present BMT because there were 
completed previous statin therapy 
• Carotid endarterectomy or carotid artery stenting 
will not likely benefit today asymptomatic 
patients unless new RCT prove it
What is BMT? 
• Lifestyle changes: smoking cessation, med diet, 
exercise 
• Statins with achieved goal about LDL cholesterol 
and complementary lipid lowering drugs if 
necessary 
• Antiplatelet therapy with aspirin or clopidogrel 
• ACE inhibitors with achieved goal of normalized 
arterial pressure during a 24h period
27 guidelines on asymptomatic carotid 
atheromatous stenosis 
Number of studies % of studies Recommendation (Carotid endarterectomy CEA, 
Carotid artery stenting CAS) 
7 26 Strong advocates for CEA 
16 59 Weak advocates for CEA 
2 7 Strong advocates for CAS 
11 41 Weak advocates for CAS 
7 26 Strong advocates AGAINST CAS 
12 44 Some support for CAS only in patients with high 
risk CEA due to vascular anomaly 
10 37 Some support for CAS only in patients with high 
risk CEA due to comorbidities 
Adapted from: 
http://www.vascularnews.com/vn-newspaper-pdfs?DocumentScreen=detail&cl=539&ccs=655
Recommendations: time dependent or 
bias variations ? (1) 
• NASCET : North American Symptomatic Carotid 
Endarterectomy Trial Collaborators. Beneficial effect of 
carotid endarterectomy in symptomatic patients with 
high-grade stenosis. N Engl J Med. 1991;325:445–453. 
• ACAS: Walker MD, Marler JR, Goldstein M, et al. 
Endarterectomy for Asymptomatic Carotid Artery 
Stenosis. JAMA. 1995;273(18):1421-1428. 
doi:10.1001/jama.1995.03520420037035. 
• SPARCL: Amarenco P, et al. High-dose atorvastatin after 
stroke or transient ischemic attack. N Engl J Med. 
2006. 355(6):549-559.
Recommendations: time dependent or 
bias variations ? (2) 
• BMT is not complete in at least 30% of patients 
• CEA could reduce by 0.5-1% RRR in asymptomatic 
patients if patient Life Expectancy exceeds 3 years 
• Routine practice shows that recommendations are not 
followed in approx. 50% of cases either by misleading 
measures, error in the status (symptomatic versus 
asymptomatic), or other bias 
• Choice between CEA vs CAS is mainly driven by the 
training of the interventionist rather than evidence 
• Industry is powerfully backing CAS because of the cost 
of implanted material versus CEA
Conclusion 
• CAS for asymptomatic patients is not indicated except 
for rare cases of stenosis progression 
• CEA for asymptomatic patients is 60-70% of the work 
load in vascular surgical centers in Europe (except UK) 
or US 
• There is clearly a better possibility for allocation of 
these resources 
• Instead vascular surgical centers should get together 
with stroke centers to improve symptomatic patient 
management and care in terms of delay and results 
• CAS does have a future in asymptomatic patients but it 
belongs to RCT

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We need to revise asymptomatic carotid atheroma guidelines

  • 1. We need to revise management guidelines of asymptomatic carotid atheroma Guy-André Pelouze MD Chirurgien des Hôpitaux Perpignan France
  • 2. Asymptomatic carotid atheroma • Carotid: which means bifurcation and doesn’t mean main carotid, brachiocephalic, subclavian or vertebral arteries. • Atheroma: of the bifurcation which doesn’t mean restenosis, radiation-induced lesion, fibrodysplasia • Asymptomatic: which means no focal, ipsilateral neurological or ocular symptom during the past six months
  • 3. The risk of stroke associated with asymptomatic atheroma of carotid bifurcation has fallen drastically • BMT (Statin/AP/ACE inhibitors) alone reduces the risk at least of 60-80% • Arteriography no longer mandatory in those patients, Duplex and angioCT don’t provoke stroke and provide more reliable imaging • Trials comparing CEA vs BMT had not taken in account present BMT because there were completed previous statin therapy • Carotid endarterectomy or carotid artery stenting will not likely benefit today asymptomatic patients unless new RCT prove it
  • 4. What is BMT? • Lifestyle changes: smoking cessation, med diet, exercise • Statins with achieved goal about LDL cholesterol and complementary lipid lowering drugs if necessary • Antiplatelet therapy with aspirin or clopidogrel • ACE inhibitors with achieved goal of normalized arterial pressure during a 24h period
  • 5. 27 guidelines on asymptomatic carotid atheromatous stenosis Number of studies % of studies Recommendation (Carotid endarterectomy CEA, Carotid artery stenting CAS) 7 26 Strong advocates for CEA 16 59 Weak advocates for CEA 2 7 Strong advocates for CAS 11 41 Weak advocates for CAS 7 26 Strong advocates AGAINST CAS 12 44 Some support for CAS only in patients with high risk CEA due to vascular anomaly 10 37 Some support for CAS only in patients with high risk CEA due to comorbidities Adapted from: http://www.vascularnews.com/vn-newspaper-pdfs?DocumentScreen=detail&cl=539&ccs=655
  • 6. Recommendations: time dependent or bias variations ? (1) • NASCET : North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade stenosis. N Engl J Med. 1991;325:445–453. • ACAS: Walker MD, Marler JR, Goldstein M, et al. Endarterectomy for Asymptomatic Carotid Artery Stenosis. JAMA. 1995;273(18):1421-1428. doi:10.1001/jama.1995.03520420037035. • SPARCL: Amarenco P, et al. High-dose atorvastatin after stroke or transient ischemic attack. N Engl J Med. 2006. 355(6):549-559.
  • 7. Recommendations: time dependent or bias variations ? (2) • BMT is not complete in at least 30% of patients • CEA could reduce by 0.5-1% RRR in asymptomatic patients if patient Life Expectancy exceeds 3 years • Routine practice shows that recommendations are not followed in approx. 50% of cases either by misleading measures, error in the status (symptomatic versus asymptomatic), or other bias • Choice between CEA vs CAS is mainly driven by the training of the interventionist rather than evidence • Industry is powerfully backing CAS because of the cost of implanted material versus CEA
  • 8. Conclusion • CAS for asymptomatic patients is not indicated except for rare cases of stenosis progression • CEA for asymptomatic patients is 60-70% of the work load in vascular surgical centers in Europe (except UK) or US • There is clearly a better possibility for allocation of these resources • Instead vascular surgical centers should get together with stroke centers to improve symptomatic patient management and care in terms of delay and results • CAS does have a future in asymptomatic patients but it belongs to RCT

Editor's Notes

  1. http://www.has-sante.fr/portail/upload/docs/application/pdf/rapport_stenoses_bifurcation_carotidienne.pdf http://www.ncbi.nlm.nih.gov/pubmed/24377944 http://www.ncbi.nlm.nih.gov/pubmed/25045271