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REVIEW  CAROTID DISEASE Editor’s choice • Free accessfree

International Angiology 2022 April;41(2):158-69

DOI: 10.23736/S0392-9590.21.04825-2

Copyright © 2021 EDIZIONI MINERVA MEDICA

language: English

Optimal management of asymptomatic carotid stenosis in 2021: the jury is still out. An international, multispecialty, expert review and position statement

Kosmas I. PARASKEVAS 1 , Dimitri P. MIKHAILIDIS 2, Pier L. ANTIGNANI 3, Hediyeh BARADARAN 4, Reinoud P.H. BOKKERS 5, Richard P. CAMBRIA 6, Alan DARDIK 7, Alun H. DAVIES 8, Hans-Henning ECKSTEIN 9, Gianluca FAGGIOLI 10, José FERNANDES E FERNANDES 11, Gustav FRAEDRICH 12, George GEROULAKOS 13, Peter GLOVICZKI 14, Jonathan GOLLEDGE 15, Ajay GUPTA 16, Mateja K. JEZOVNIK 17, Stavros K. KAKKOS 18, Niki KATSIKI 19, Michael KNOFLACH 20, M. Eline KOOI 21, 22, Gaetano LANZA 23, Christos D. LIAPIS 24, Ian M. LOFTUS 25, Armando MANSILHA 26, 27, Antoine MILLON 28, Andrew N. NICOLAIDES 29, Rodolfo PINI 10, Pavel POREDOS 30, Jean-Baptiste RICCO 31, Thomas S. RILES 32, Peter Arthur RINGLEB 33, Tatjana RUNDEK 34, Luca SABA 35, Felix SCHLACHETZKI 36, Mauro SILVESTRINI 37, Francesco SPINELLI 38, Francesco STILO 38, Sherif SULTAN 39, Jasjit S. SURI 40, Clark J. ZEEBREGTS 41, Seemant CHATURVEDI 42

1 Department of Vascular Surgery, Central Clinic of Athens, Athens, Greece; 2 Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, UK; 3 Vascular Center, Nuova Villa Claudia, Rome, Italy; 4 Department of Radiology, University of Utah, Salt Lake City, UT, USA; 5 Department of Radiology, Medical Imaging Center, University Medical Center Groningen, Groningen, the Netherlands; 6 Division of Vascular and Endovascular Surgery, St. Elizabeth’s Medical Center, Brighton, MA, USA; 7 Division of Vascular and Endovascular Surgery, Yale University School of Medicine, New Haven, CT, USA; 8 Section of Vascular Surgery, Imperial College & Imperial Healthcare NHS Trust, London, UK; 9 Department for Vascular and Endovascular Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany; 10 Vascular Surgery, Alma Mater Studiorum University of Bologna, Policlinico S. Orsola Malpighi, Bologna, Italy; 11 Department of Vascular Surgery, University of Lisbon, Lisbon Academic Medical Center, Lisbon, Portugal; 12 Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria; 13 Department of Vascular Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece; 14 Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA; 15 Queensland Research Centre for Peripheral Vascular Disease, James Cook University and Townsville University Hospital, Townsville, Queensland, Australia; 16 Department of Radiology, Weill Cornell Medicine, New York, NY, USA; 17 Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Centre at Houston, Houston, TX, USA; 18 Department of Vascular Surgery, University of Patras Medical School, Patras, Greece; 19 First Department of Internal Medicine, AHEPA University Hospital, Thessaloniki, Greece; 20 Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria; 21 CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, the Netherlands; 22 Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, the Netherlands; 23 Vascular Surgery Department, IRCSS MultiMedica Hospital, Castellanza, Italy; 24 Athens Vascular Research Center, Athens, Greece; 25 St. George’s Vascular Institute, St. George’s University London, London, UK; 26 Faculty of Medicine of the University of Porto, Porto, Portugal; 27 Department of Angiology and Vascular Surgery, Hospital de S. Joao, Porto, Portugal; 28 Department of Vascular and Endovascular Surgery, Louis Pradel Hospital, Hospices Civils de Lyon, France; 29 Department of Surgery, University of Nicosia Medical School, Nicosia, Cyprus; 30 Department of Vascular Disease, University Medical Centre Ljubljana, Slovenia; 31 Department of Clinical Research, University of Poitiers, CHU de Poitiers, Poitiers, France; 32 Department of Surgery, Division of Vascular Surgery, New York University Langone Medical Centre, New York, NY, USA; 33 Department of Neurology, University Hospital, Heidelberg, Germany; 34 Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, USA; 35 Department of Radiology, Azienda Ospedaliera Universitaria di Cagliari, Cagliari, Italy; 36 Department of Neurology, University of Regensburg, Regensburg, Germany; 37 Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy; 38 Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy; 39 Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Galway, Ireland; 40 Stroke Diagnosis and Monitoring Division, AtheroPointTM, Roseville, MI, USA; 41 Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands; 42 Department of Neurology & Stroke Program, University of Maryland School of Medicine, Baltimore, MD, USA



The recommendations of international guidelines for the management of asymptomatic carotid stenosis (ACS) often vary considerably and extend from a conservative approach with risk factor modification and best medical treatment (BMT) alone, to a more aggressive approach with a carotid intervention plus BMT. The aim of the current multispecialty position statement was to reconcile the conflicting views on the topic. A literature review was performed with a focus on data from recent studies. Several clinical and imaging high-risk features have been identified that are associated with an increased long-term ipsilateral ischemic stroke risk in patients with ACS. Such high-risk clinical/imaging features include intraplaque hemorrhage, impaired cerebrovascular reserve, carotid plaque echolucency/ulceration/ neovascularization, a lipid-rich necrotic core, a thin or ruptured fibrous cap, silent brain infarction, a contralateral transient ischemic attack/stroke episode, male patients <75 years and microembolic signals on transcranial Doppler. There is growing evidence that 80-99% ACS indicate a higher stroke risk than 50-79% stenoses. Although aggressive risk factor control and BMT should be implemented in all ACS patients, several high-risk features that may increase the risk of a future cerebrovascular event are now documented. Consequently, some guidelines recommend a prophylactic carotid intervention in high-risk patients to prevent future cerebrovascular events. Until the results of the much-anticipated randomized controlled trials emerge, the jury is still out regarding the optimal management of ACS patients.


KEY WORDS: Carotid stenosis; Stroke; Endarterectomy, carotid

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