Abstract
Management of carotid bifurcation stenosis is a cornerstone of stroke prevention and has been the subject of extensive clinical investigation, including multiple controlled randomized trials. The appropriate treatment of patients with carotid bifurcation disease is of major interest to the community of vascular surgeons. In 2008, the Society for Vascular Surgery published guidelines for treatment of carotid artery disease. At the time, only one randomized trial, comparing carotid endarterectomy (CEA) and carotid stenting (CAS), had been published. Since that publication, four major randomized trials comparing CEA and CAS have been published, and the role of medical management has been re-emphasized. The current publication updates and expands the 2008 guidelines with specific emphasis on six areas: imaging in identification and characterization of carotid stenosis, medical therapy (as stand-alone management and also in conjunction with intervention in patients with carotid bifurcation stenosis), risk stratification to select patients for appropriate interventional management (CEA or CAS), technical standards for performing CEA and CAS, the relative roles of CEA and CAS, and management of unusual conditions associated with extracranial carotid pathology. Recommendations are made using the GRADE (Grades of Recommendation Assessment, Development and Evaluation) system, as has been done with other Society for Vascular Surgery guideline documents. In contrast to the multispecialty guidelines recently published, the committee recommends CEA as the first-line treatment for most symptomatic patients with stenosis of 50% to 99% and asymptomatic patients with stenosis of 60% to 99%. The perioperative risk of stroke and death in asymptomatic patients must be <3% to ensure benefit for the patient. CAS should be reserved for symptomatic patients with stenosis of 50% to 99% at high risk for CEA for anatomic or medical reasons. CAS is not recommended for asymptomatic patients at this time. Asymptomatic patients at high risk for intervention or with <3 years life expectancy should be considered for medical management as the first-line therapy.
| Original language | English (US) |
|---|---|
| Pages (from-to) | e1-e31 |
| Journal | Journal of Vascular Surgery |
| Volume | 54 |
| Issue number | 3 |
| DOIs | |
| State | Published - Sep 2011 |
Funding
Given these assumptions, screening of the general population is not indicated. This position is supported by multiple professional organizations, including the National Stroke Association, 22 the Canadian Stroke Consortium 23 and the U.S. Preventive Services Task Force. 24 The American Stroke Association/AHA Stroke Council 25 concluded that highly selected patient populations may benefit, but screening of the general population for asymptomatic carotid stenosis was unlikely to be cost-effective and might have the potential adverse effect of false-negative or false-positive results. Finally, the American College of Cardiology Foundation, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and American Society of Interventional & Therapeutic Neuroradiology Clinical Expert Consensus Panel on Carotid Stenting recommended screening for asymptomatic patients with carotid bruit who are potential candidates for carotid intervention and for those in whom coronary artery bypass grafting (CABG) is planned. 26
ASJC Scopus subject areas
- Cardiology and Cardiovascular Medicine
- Surgery
