REVIEW  CAROTID DISEASE Editor’s choice • Free access

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

DOI: 10.23736/S0392-9590.21.04825-2

Copyright © 2021 EDIZIONI MINERVA MEDICA

lingua: Inglese

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