REVIEW  CAROTID DISEASE Free access

International Angiology 2021 December;40(6):487-96

DOI: 10.23736/S0392-9590.21.04751-9

Copyright © 2021 EDIZIONI MINERVA MEDICA

language: English

Management of patients with asymptomatic carotid stenosis may need to be individualized: a multidisciplinary call for action. Republication of J Stroke 2021;23:202-212

Kosmas I. PARASKEVAS ¹ ✉, Dimitri P. MIKHAILIDIS ², Hediyeh BARADARAN ³, Alun H. DAVIES ⁴, Hans-Henning ECKSTEIN ⁵, Gianluca FAGGIOLI ⁶, Jose FERNANDES E FERNANDES ⁷, Ajay GUPTA ⁸, Mateja K. JEZOVNIK ⁹, Stavros K. KAKKOS ¹⁰, Niki KATSIKI ¹¹, M. Eline KOOI ^{12, 13}, Gaetano LANZA ¹⁴, Christos D. LIAPIS ¹⁵, Ian M. LOFTUS ¹⁶, Antoine MILLON ¹⁷, Andrew N. NICOLAIDES ¹⁸, Pavel POREDOS ¹⁹, Rodolfo PINI ⁶, Jean-Baptiste RICCO ²⁰, Tatjana RUNDEK ²¹, Luca SABA ²², Francesco SPINELLI ²³, Francesco STILO ²³, Sherif SULTAN ²⁴, Clark J. ZEEBREGTS ²⁵, Seemant CHATURVEDI ²⁶

¹ Department of Vascular Surgery, Central Clinic of Athens, Athens, Greece; ² University College London Medical School, Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London (UCL), London, UK; ³ Department of Radiology, University of Utah, Salt Lake City, UT, USA; ⁴ Section of Vascular Surgery, Imperial College and Imperial Healthcare NHS Trust, London, UK; ⁵ Department of Vascular and Endovascular Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany; ⁶ Unit of Vascular Surgery, University of Bologna, S. Orsola Malpighi Polyclinic, Bologna, Italy; ⁷ Department of Vascular Surgery, Lisbon Academic Medical Center, University of Lisbon, Lisbon, Portugal; ⁸ Department of Radiology, Weill Cornell Medicine, New York, NY, USA; ⁹ Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Centre at Houston, Houston, TX, USA; ¹⁰ School of Medicine, Department of Vascular Surgery, University of Patras, Patras, Greece; ¹¹ First Department of Internal Medicine, AHEPA University Hospital, Thessaloniki, Greece; ¹² CARIM School for Cardiovascular Diseases, University of Maastricht, Maastricht, the Netherlands; ¹³ Department of Radiology and Nuclear Medicine, Maastricht University Medical Center (MUMC), Maastricht, the Netherlands; ¹⁴ Department of Vascular Surgery, IRCSS MultiMedica Hospital, Castellanza, Varese, Italy; ¹⁵ Athens Vascular Research Center, Athens, Greece; ¹⁶ St. George’s Vascular Institute, St. George’s University of London, London, UK; ¹⁷ Department of Vascular and Endovascular Surgery, Hospices Civils de Lyon, Louis Pradel Hospital, Yon, France; ¹⁸ Department of Surgery, University of Nicosia Medical School, Nicosia, Cyprus; ¹⁹ Department of Vascular Disease, University Medical Center, Ljubljana, Slovenia; ²⁰ Department of Clinical Research, CHU de Poitiers, University of Poitiers, Poitiers, France; ²¹ Miller School of Medicine, Department of Neurology, University of Miami, Miami, FL, USA; ²² Department of Radiology, University Hospital of Cagliari, Cagliari, Italy; ²³ Division of Vascular Surgery, Campus Bio-Medico Hospital, University of Rome, Rome, Italy; ²⁴ Department of Vascular and Endovascular Surgery, University Western Vascular Institute, Hospital Galway, National University of Ireland, Galway, Ireland; ²⁵ Division of Vascular Surgery, Department of Surgery, University Medical Center of Groningen, University of Groningen, Groningen, the Netherlands; ²⁶ School of Medicine, Department of Neurology and Stroke Program, University of Maryland, Baltimore, MD, USA

The optimal management of patients with asymptomatic carotid stenosis (ACS) is the subject of extensive debate. According to the 2017 European Society for Vascular Surgery Guidelines, carotid endarterectomy should (Class IIa; Level of Evidence: B) or carotid artery stenting may be considered (Class IIb; Level of Evidence: B) in the presence of one or more clinical/imaging characteristics that may be associated with an increased risk of late ipsilateral stroke (e.g. silent embolic infarcts on brain computed tomography/magnetic resonance imaging, progression in the severity of ACS, a history of contralateral transient ischemic attack/stroke, microemboli detection on transcranial Doppler, etc.), provided documented perioperative stroke/death rates are <3% and the patient’s life expectancy is >5 years. Besides these clinical/imaging characteristics, there are additional individual, ethnic/racial or social factors that should probably be evaluated in the decision process regarding the optimal management of these patients, such as individual patient needs/patient choice, patient compliance with best medical treatment, patient sex, culture, race/ethnicity, age and comorbidities, as well as improvements in imaging/operative techniques/outcomes. The present multispecialty position paper will present the rationale why the management of patients with ACS may need to be individualized.

KEY WORDS: Carotid stenosis; Endarterectomy, carotid; Stroke