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The Journal of Cardiovascular Surgery 2022 August;63(4):471-91

DOI: 10.23736/S0021-9509.22.12368-2

Copyright © 2022 THE AUTHORS

This is an open access article distributed under the terms of the CC BY-NC 4.0 license which allows users to distribute, remix, adapt and build upon the manuscript, as long as this is not done for commercial purposes, the user gives appropriate credits to the original author(s) and the source (with a link to the formal publication through the relevant DOI), provides a link to the license and indicates if changes were made.

language: English

Guideline on carotid surgery for stroke prevention: updates from the Italian Society of Vascular and Endovascular Surgery. A trend towards personalized medicine

Gaetano LANZA 1, Massimiliano ORSO 2, Giuseppe ALBA 3, Sergio BEVILACQUA 4, Laura CAPOCCIA 5, Alessandro CAPPELLI 3, Giampaolo CARRAFIELLO 6, Carlo CERNETTI 7, 8, Marina DIOMEDI 9, Walter DORIGO 10, Gianluca FAGGIOLI 11, Vanni GIANNACE 3, David GIANNANDREA 12, Matteo GIANNETTA 13, Jessica LANZA 14 , Gianfranco LESSIANI 15, Enrico M. MARONE 16, Daniela MAZZACCARO 13, Rino MIGLIACCI 17, Giovanni NANO 13, Gabriele PAGLIARICCIO 18, Marco PETRUZZELLIS 19, Andrea PLUTINO 20, Sara POMATTO 21, Raffaele PULLI 22, Nicoletta REALE 23, Paola SANTALUCIA 23, Pasqualino SIRIGNANO 5, Giulia TICOZZELLI 24, Andrea VACIRCA 25, Emanuele VISCO 26

1 Department of Vascular Surgery, IRCCS MultiMedica, Castellanza Hospital, Castellanza, Varese, Italy; 2 Experimental Zooprophylactic Institute of Umbria and Marche, Perugia, Italy; 3 Unit of Vascular Surgery, Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy; 4 Department of Cardiac Anesthesia and Resuscitation, Careggi University Hospital, Florence, Italy; 5 Department of Vascular and Endovascular Surgery, Umberto I Polyclinic Hospital, Sapienza University, Rome, Italy; 6 Department of Radiology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy; 7 Department of Cardiology and Hemodynamics, San Giacomo Apostolo Hospital, Castelfranco Veneto, Treviso, Italy; 8 Cardiology and Hemodynamics Unit, Ca’ Foncello Hospital, Treviso, Italy; 9 Stroke Unit, Tor Vergata Polyclinic Hospital, Tor Vergata University, Rome, Italy; 10 Department of Vascular Surgery, Careggi Polyclinic Hospital, University of Florence, Florence, Italy; 11 Department of Vascular Surgery, Alma Mater Studiorum University, Bologna, Italy; 12 Department of Neurology, USL Umbria 1, Hospitals of Gubbio, Gualdo Tadino and Città di Castello, Perugia, Italy; 13 Department of Vascular Surgery, IRCCS San Donato Hospitals, San Donato Polyclinic Hospital, Milan, Italy; 14 Department of Vascular Surgery, IRCCS San Martino Polyclinic Hospital, University of Genoa, Genoa, Italy; 15 Unit of Vascular Medicine and Diagnostics, Department of Internal Medicine, Villa Serena Hospital, Città Sant’Angelo, Pesaro, Italy; 16 Vascular Surgery, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy; 17 Department of Internal Medicine, Valdichiana S. Margherita Hospital, USL Toscana Sud-Est, Cortona, Arezzo, Italy; 18 Department of Emergency Vascular Surgery, Ospedali Riuniti University of Ancona, Ancona, Italy; 19 Neurology and Stroke Unit, University of Bari, Bari, Italy; 20 Stroke Unit, Ospedali Riuniti Marche Nord, Ancona, Italy; 21 Department of Vascular Surgery, Sant’Orsola Malpighi Polyclinic Hospital, University of Bologna, Bologna, Italy; 22 Department of Vascular Surgery, University of Bari, Bari, Italy; 23 A.L.I.Ce. Italia Nonprofit Organization, Rome, Italy; 24 First Department of Anesthesia and Resuscitation, IRCCS Policlinico San Matteo Foundation, Pavia, Italy; 25 Unit of Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), IRCSS Sant’Orsola Polyclinic Hospital, University of Bologna, Bologna, Italy; 26 Department of Cardiology and Hemodynamics, San Giacomo Apostolo Hospital, Castelfranco Veneto, Treviso, Italy

BACKGROUND: This guideline (GL) on carotid surgery as updating of “Stroke: Italian guidelines for Prevention and Treatment” of the ISO-SPREAD Italian Stroke Organization-Group, has recently been published in the National Guideline System and shared with the Italian Society of Vascular and Endovascular Surgery (SICVE) and other Scientific Societies and Patient’s Association.
METHODS: GRADE-SIGN version, AGREE quality of reporting checklist. Clinical questions formulated according to the PICO model. Recommendations developed based on clinical questions by a multidisciplinary experts’ panel and patients’ representatives. Systematic reviews performed for each PICO question. Considered judgements filled by assessing the evidence level, direction, and strength of the recommendations.
RESULTS: The panel provided indications and recommendations for appropriate, comprehensive, and individualized management of patients with carotid stenosis. Diagnostic and therapeutic processes of the best medical therapy, carotid endarterectomy (CEA), carotid stenting (CAS) according to the evidences and the judged opinions were included. Symptomatic carotid stenosis in elective and emergency, asymptomatic carotid stenosis, association with ischemic heart disease, preoperative diagnostics, types of anesthesia, monitoring in case of CEA, CEA techniques, comparison between CEA and CAS, post-surgical carotid restenosis, and medical therapy are the main topics, even with analysis of uncertainty areas for risk-benefit assessments in the individual patient (personalized medicine [PM]).
CONCLUSIONS: This GL updates on the main recommendations for the most appropriate diagnostic and medical-surgical management of patients with atherosclerotic carotid artery stenosis to prevent ischemic stroke. This GL also provides useful elements for the application of PM in good clinical practice.

KEY WORDS: Carotid stenosis; Stroke; Prevention and control; Precision medicine; Guideline

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