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Australian Journal of General Practice Nov 2021Carotid artery stenosis (CAS) is one of the major causes of acute ischaemic stroke, accounting for approximately 20% of cases. It is not always symptomatic; however,... (Review)
Review
BACKGROUND
Carotid artery stenosis (CAS) is one of the major causes of acute ischaemic stroke, accounting for approximately 20% of cases. It is not always symptomatic; however, when it is, the neurological vascular territory it commonly affects is the anterior circulation of the brain, causing symptoms such as hemiplegia, dysphasia or vision loss.
OBJECTIVE
The aim of this article is to review the current literature on CAS, summarise the main updates and evidence base for surgical management, and discuss when vascular surgical input may be beneficial.
DISCUSSION
CAS can be classified as symptomatic or asymptomatic disease. Carotid endarterectomy remains important in the treatment of symptomatic disease because of a strong evidence base for its benefit in the overall reduction of recurrent stroke risk. The benefit of surgery is less clear for asymptomatic disease. Commencement of best medical therapy as well as cardiovascular risk factor modification is a mainstay of treatment for both groups of patients.
Topics: Brain Ischemia; Carotid Stenosis; Humans; Risk Factors; Stroke; Treatment Outcome
PubMed: 34713283
DOI: 10.31128/AJGP-10-20-5664 -
Journal of Vascular Surgery Jan 2022Management of carotid bifurcation stenosis in stroke prevention has been the subject of extensive investigations, including multiple randomized controlled trials. The... (Meta-Analysis)
Meta-Analysis
Management of carotid bifurcation stenosis in stroke prevention has been the subject of extensive investigations, including multiple randomized controlled trials. The proper treatment of patients with carotid bifurcation disease is of major interest to vascular surgeons and other vascular specialists. In 2011, the Society for Vascular Surgery published guidelines for the treatment of carotid artery disease. At the time, several randomized trials, comparing carotid endarterectomy (CEA) and carotid artery stenting (CAS), were reported. Since the 2011 guidelines, several studies and a few systematic reviews comparing CEA and CAS have been reported, and the role of medical management has been reemphasized. In the present publication, we have updated and expanded on the 2011 guidelines with specific emphasis on five areas: (1) is CEA recommended over maximal medical therapy for low-risk patients; (2) is CEA recommended over transfemoral CAS for low surgical risk patients with symptomatic carotid artery stenosis of >50%; (3) the timing of carotid intervention for patients presenting with acute stroke; (4) screening for carotid artery stenosis in asymptomatic patients; and (5) the optimal sequence of intervention for patients with combined carotid and coronary artery disease. A separate implementation document will address other important clinical issues in extracranial cerebrovascular disease. Recommendations are made using the GRADE (grades of recommendation assessment, development, and evaluation) approach, as was used for other Society for Vascular Surgery guidelines. The committee recommends CEA as the first-line treatment for symptomatic low-risk surgical patients with stenosis of 50% to 99% and asymptomatic patients with stenosis of 70% to 99%. The perioperative risk of stroke and death in asymptomatic patients must be <3% to ensure benefit for the patient. In patients with recent stable stroke (modified Rankin scale score, 0-2), carotid revascularization is considered appropriate for symptomatic patients with >50% stenosis and should be performed as soon as the patient is neurologically stable after 48 hours but definitely <14 days after symptom onset. In the general population, screening for clinically asymptomatic carotid artery stenosis in patients without cerebrovascular symptoms or significant risk factors for carotid artery disease is not recommended. In selected asymptomatic patients with an increased risk of carotid stenosis, we suggest screening for clinically asymptomatic carotid artery stenosis as long as the patients would potentially be fit for and willing to consider carotid intervention if significant stenosis is discovered. For patients with symptomatic carotid stenosis of 50% to 99%, who require both CEA and coronary artery bypass grafting, we suggest CEA before, or concomitant with, coronary artery bypass grafting to potentially reduce the risk of stroke and stroke/death. The sequencing of the intervention depends on the clinical presentation and institutional experience.
Topics: Cardiovascular Agents; Carotid Stenosis; Clinical Decision-Making; Consensus; Endarterectomy, Carotid; Endovascular Procedures; Evidence-Based Medicine; Humans; Risk Assessment; Risk Factors; Treatment Outcome
PubMed: 34153348
DOI: 10.1016/j.jvs.2021.04.073 -
Arquivos de Neuro-psiquiatria Apr 2022
Topics: Carotid Artery, Internal; Carotid Stenosis; Humans
PubMed: 35613217
DOI: 10.1590/0004-282X-ANP-2022-E004 -
Journal of Vascular Surgery Sep 2023Sex differences regarding the safety and efficacy of carotid revascularization in carotid artery stenosis have been addressed in several studies with conflicting... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
Sex differences regarding the safety and efficacy of carotid revascularization in carotid artery stenosis have been addressed in several studies with conflicting results. Moreover, women are underrepresented in clinical trials, leading to limited conclusions regarding the safety and efficacy of acute stroke treatments.
METHODS
A systematic review and meta-analysis was performed by literature search including four databases from January 1985 to December 2021. Sex differences in the efficacy and safety of revascularization procedures, including carotid endarterectomy (CEA) and carotid artery stenting (CAS), for symptomatic and asymptomatic carotid artery stenoses were analyzed.
RESULTS
Regarding CEA in symptomatic carotid artery stenosis, the stroke risk in men (3.6%) and women (3.9%) based on 99,495 patients (30 studies) did not differ (P = .16). There was also no difference in the stroke risk by different time frames up to 10 years. Compared with men, women treated with CEA had a significantly higher stroke or death rate at 4 months (2 studies, 2565 patients; 7.2% vs 5.0%; odds ratio [OR], 1.49; 95% confidence interval [CI], 1.04-2.12; I = 0%; P = .03), and a significantly higher rate of restenosis (1 study, 615; 17.2% vs 6.7%; OR, 2.81; 95% CI, 1.66-4.75; P = .0001). For CAS in symptomatic artery stenosis, data showed a non-significant tendency toward higher peri-procedural stroke in women, whereas for asymptomatic carotid artery stenosis, data based on 332,344 patients showed that women (compared with men) after CEA had similar rates of stroke, stroke or death, and the composite outcome stroke/death/myocardial infarction. The rate of restenosis at 1 year was significantly higher in women compared with men (1 study, 372 patients; 10.8% vs 3.2%; OR, 3.71; 95% CI, 1.49-9.2; P = .005). Furthermore, CAS in asymptomatic patients was associated with low risk of a postprocedural stroke in both sexes, but a significantly higher risk of in-hospital myocardial infarction in women than men (8445 patients, 1.2% vs 0.6%; OR, 2.01; 95% CI, 1.23-3.28; I = 0%; P = .005).
CONCLUSIONS
A few sex-differences in short-term outcomes after carotid revascularization for symptomatic and asymptomatic carotid artery stenosis were found, although there were no significant differences in the overall stroke. This indicates a need for larger multicenter prospective studies to evaluate these sex-specific differences. More women, including those aged over 80 years, need to be enrolled in randomized controlled trials, to better understand if sex differences exist and to tailor carotid revascularization accordingly.
Topics: Humans; Female; Male; Aged, 80 and over; Carotid Stenosis; Sex Characteristics; Prospective Studies; Treatment Outcome; Stents; Endarterectomy, Carotid; Carotid Arteries; Stroke; Myocardial Infarction; Constriction, Pathologic; Risk Factors; Risk Assessment; Multicenter Studies as Topic
PubMed: 37055001
DOI: 10.1016/j.jvs.2023.03.502 -
F1000Research 2020Despite the completion of several multi-center trials, the management of carotid stenosis remains in flux. Key questions include the role of intensive medical management... (Review)
Review
Despite the completion of several multi-center trials, the management of carotid stenosis remains in flux. Key questions include the role of intensive medical management in the treatment of asymptomatic carotid stenosis. In addition, identification of patients with symptomatic stenosis who will most benefit from carotid revascularization remains a priority. The role of newer imaging techniques such as carotid plaque analysis with magnetic resonance imaging is also challenging current treatment paradigms. These topics are explored in this topical update.
Topics: Carotid Stenosis; Endovascular Procedures; Humans; Magnetic Resonance Imaging; Plaque, Atherosclerotic
PubMed: 32802315
DOI: 10.12688/f1000research.25922.1 -
Journal of Vascular Surgery Oct 2021Balance and mobility function worsen with age, more so for those with underlying chronic diseases. We recently found that asymptomatic carotid artery stenosis (ACAS)...
OBJECTIVE
Balance and mobility function worsen with age, more so for those with underlying chronic diseases. We recently found that asymptomatic carotid artery stenosis (ACAS) restricts blood flow to the brain and might also contribute to balance and mobility impairment. In the present study, we tested the hypothesis that ACAS is a modifiable risk factor for balance and mobility impairment. Our goal was to assess the effect of restoring blood flow to the brain by carotid revascularization on the balance and mobility of patients with high-grade ACAS (≥70% diameter-reducing stenosis).
METHODS
Twenty adults (age, 67.0 ± 9.4 years) undergoing carotid endarterectomy for high-grade stenosis were enrolled. Balance and mobility assessments were performed before and 6 weeks after revascularization. These included the Short Physical Performance Battery, the Berg Balance Scale, the Four Square Step Test, the Dynamic Gait Index (DGI), the Timed Up and Go test, gait speed, the Mini-Balance Evaluation Systems Test (Mini-BESTest), and the Walking While Talking complex test.
RESULTS
Consistent with our previous findings, patients demonstrated reduced scores on the Short Physical Performance Battery, Berg Balance Scale, DGI, and Timed Up and Go test and in gait speed. Depending on the outcome measure, 25% to 90% of the patients had scored in the impaired range at baseline. After surgery, significant improvements were observed in the outcome measures that combined walking with dynamic movements, including the DGI (P = .02) and Mini-BESTest (P = .002). The proportion of patients with Mini-BESTest scores indicating a high fall risk had decreased significantly from 90% (n = 18) at baseline to 40% (n = 8) after surgery (P = .02). We used Pearson's correlations to examine the relationship between balance and mobility before surgery and the change after surgery. Patients with lower baseline DGI and Mini-BESTest scores demonstrated the most improvement after surgery (r = -0.59, P = .006; and r = -0.70, P = .001, respectively).
CONCLUSIONS
Carotid revascularization improved patients' balance and mobility, especially for measures that combine walking and dynamic movements. The greatest improvements were observed for the patients who had been most impaired at baseline.
Topics: Accidental Falls; Age Factors; Aged; Asymptomatic Diseases; Brain; Carotid Stenosis; Cerebrovascular Circulation; Endarterectomy, Carotid; Female; Functional Status; Humans; Male; Middle Aged; Mobility Limitation; Postural Balance; Recovery of Function; Risk Factors; Time Factors; Treatment Outcome; Walking
PubMed: 34019991
DOI: 10.1016/j.jvs.2021.04.056 -
Biomedical Engineering Online May 2019In the past few decades, imaging has been developed to a high level of sophistication. Improvements from one-dimension (1D) to 2D images, and from 2D images to 3D... (Review)
Review
In the past few decades, imaging has been developed to a high level of sophistication. Improvements from one-dimension (1D) to 2D images, and from 2D images to 3D models, have revolutionized the field of imaging. This not only helps in diagnosing various critical and fatal diseases in the early stages but also contributes to making informed clinical decisions on the follow-up treatment profile. Carotid artery stenosis (CAS) may potentially cause debilitating stroke, and its accurate early detection is therefore important. In this paper, the technical development of various CAS diagnosis imaging modalities and its impact on the clinical efficacy is thoroughly reviewed. These imaging modalities include duplex ultrasound (DUS), computed tomography angiography (CTA) and magnetic resonance angiography (MRA). For each of the imaging modalities considered, imaging methodology (principle), critical imaging parameters, and the extent of imaging the vulnerable plaque are discussed. DUS is usually the initial recommended CAS diagnostic examination. However, for the therapeutic intervention, either MRA or CTA is recommended for confirmation, and for added information on intracranial cerebral circulation and aortic arch condition for procedural planning. Over the past few decades, the focus of CAS diagnosis has also shifted from pure stenosis quantification to plaque characterization. This has led to further advancement in the existing imaging tools and development of other potential imaging tools like Optical coherence tomography (OCT), photoacoustic tomography (PAT), and infrared (IR) thermography.
Topics: Carotid Stenosis; Diagnostic Imaging; Humans
PubMed: 31138235
DOI: 10.1186/s12938-019-0685-7 -
European Journal of Vascular and... May 2023Management of asymptomatic carotid artery stenosis (ACAS), including carotid endarterectomy (CEA), carotid artery stenting (CAS), and best medical treatment (BMT),... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
Management of asymptomatic carotid artery stenosis (ACAS), including carotid endarterectomy (CEA), carotid artery stenting (CAS), and best medical treatment (BMT), remains inconsistent in current practice. Early studies reported a benefit of CEA vs. BMT; however, the current risk-benefit profile of invasive therapy lacks consensus. By evaluating the effects of modern BMT vs. invasive intervention on patient outcomes, this study aimed to influence the future management of ACAS.
METHODS
A systematic review and series of network meta-analyses were performed assessing peri-operative (within 30 days) and long term (30 days - 5 years) stroke and mortality risk between ACAS interventions. Total stroke, major, minor, ipsilateral, and contralateral stroke subtypes were assessed independently. Traditional (pre-2000) and modern (post-2000) BMT were compared to assess clinical improvements in medical therapy over the previous two decades. Risks of myocardial infarction (MI) and cranial nerve injury (CNI) were also assessed.
RESULTS
Seventeen reports of 14 310 patients with > 50% ACAS were included. CEA reduced the odds of a peri-operative stroke event occurring vs. CAS (odds ratio [OR] 1.6, 95% confidence interval [CI] 1.1 - 2.2 [0 - 20 fewer/1 000]). CEA and CAS reduced the long term odds of minor strokes (OR 0.35, 95% CI 0.21 - 0.59 [20 fewer/1 000]) and ipsilateral strokes (OR 0.27, 95% CI 0.19 - 0.39 [30 fewer/1 000]) vs. all BMT. CEA reduced the odds of major strokes and combined stroke and mortality vs. traditional BMT; however, no difference was found between CEA and modern BMT. CAS reduced the odds of peri-operative MI (OR 0.49, 95% CI 0. 26 - 0.91) and CNI (OR 0.07, 95% CI 0.01 - 0.42) vs. CEA.
CONCLUSION
Modern BMT demonstrates similar reductions in major stroke, combined stroke, and mortality to CEA. The overall risk reductions are low and data were unavailable to assess subgroups which may benefit from intervention. However, BMT carries the potential to reduce the requirement for surgical intervention in patients with ACAS.
Topics: Humans; Carotid Stenosis; Network Meta-Analysis; Risk Factors; Treatment Outcome; Stents; Endarterectomy, Carotid; Risk Assessment; Stroke; Myocardial Infarction
PubMed: 36682406
DOI: 10.1016/j.ejvs.2023.01.020 -
Acta Neurologica Taiwanica Dec 2021The incidence of both ischemic and hemorrhagic stroke is more common in Asians compared to Caucasian (1). It is found there is a decreased incidence of ischemic stroke...
The incidence of both ischemic and hemorrhagic stroke is more common in Asians compared to Caucasian (1). It is found there is a decreased incidence of ischemic stroke in Northern America but increased incidence in Africa, Mongolia and southeast Asia. In the epidemiological study of carotid artery stenosis (CAS), Framingham study showed the prevalence of significant extracranial CAS was 7% in women and 9% in men (2). Among all strokes in Caucasian population, 20 to 30% were due to extracranial CAS and 5 to 10% due to intracranial atherosclerosis (3, 4). Northern Manhattan stroke study also found intracranial atherosclerosis could be seen in 6 to 10% of ischemic strokes in white patients, but up to 29% among African Americans and Hispanics (5). Intracranial artery stenosis was more frequently found in Chinese population than extracranial artery stenosis with the range of 3.7% - 70.4% of intracranial CAS and 1.5%-49% of extracranial CAS (6). Intracranial artery stenosis is more common in Asian, Hispanic, and African-American populations. In hospitalized patients with symptomatic intracranial stenosis, it was only 1% in non-Hispanic whites, while 50% in Asian populations. Population-based studies revealed the prevalence of symptomatic intracranial disease was 1 in 100,000 for whites to 15 in 100,000 for African Americans, but 7% of the population aged more than 40 years for Chinese (7). Concurrent atherosclerosis of extracranial and intracranial arteries was also common in Asians. It was reported 10% to 48% in patients with symptomatic cerebrovascular disease, and 21% of stroke patients had concurrent stenoses in Hong Kong, 33% in China, 18% in Taiwan, and 48% of patients with more than 30% extracranial carotid stenosis had concurrent intracranial stenosis in South Korea (8). The study of concomitant atherosclerotic arterial diseases showed in patients with more than 50% significant CAS, the most frequent artery was coronary artery disease which was found in 68% of patients, while renal artery stenosis and limb artery stenosis were found in 20% and 21% of patients, respectively (9). Carotid artery stenosis of 70% or greater was detected in 37.7% patients with cerebrovascular disease, 24.5% patients with peripheral arterial disease, and 11.1% patients with coronary artery disease (10). Significant extracranial carotid and vertebral artery disease (ECCVD) identified by duplex ultrasonography is not uncommon in Chinese patients with coronary artery disease (CAD), and 22.9% ECCVD was seen in patients with CAD, comparable with that reported in white populations (11). In our Stroke Registry In Chang-Gung Healthcare System (SRICHS) from 2008 to 2011 (Fig. 1), we found large artery atherosclerosis (LAA) occupied 19.5% of total ischemic stroke patients and 3.1% had concurrent atrial fibrillation (12).
Topics: Carotid Artery Diseases; Carotid Stenosis; Female; Humans; Intracranial Arteriosclerosis; Male; Risk Factors; Stroke
PubMed: 34841497
DOI: No ID Found -
JAMA May 2022Optimal management of patients with asymptomatic severe carotid stenosis is uncertain, due to advances in medical care and a lack of contemporary data comparing medical...
IMPORTANCE
Optimal management of patients with asymptomatic severe carotid stenosis is uncertain, due to advances in medical care and a lack of contemporary data comparing medical and surgical treatment.
OBJECTIVE
To estimate stroke outcomes among patients with medically treated asymptomatic severe carotid stenosis who did not undergo surgical intervention.
DESIGN, SETTING, AND PARTICIPANTS
Retrospective cohort study that included 3737 adult participants with asymptomatic severe (70%-99%) carotid stenosis diagnosed between 2008 and 2012 and no prior intervention or ipsilateral neurologic event in the prior 6 months. Participants received follow-up through 2019, and all were members of an integrated US regional health system serving 4.5 million members.
EXPOSURES
Imaging diagnosis of asymptomatic carotid stenosis of 70% to 99%.
MAIN OUTCOMES AND MEASURES
Occurrence of ipsilateral carotid-related acute ischemic stroke. Censoring occurred with death, disenrollment, or ipsilateral intervention.
RESULTS
Among 94 822 patients with qualifying imaging studies, 4230 arteries in 3737 (mean age, 73.8 [SD 9.5 years]; 57.4% male) patients met selection criteria including 2539 arteries in 2314 patients who never received intervention. The mean follow-up in this cohort was 4.1 years (SD 3.6 years). Prior to any intervention, there were 133 ipsilateral strokes with a mean annual stroke rate of 0.9% (95% confidence interval [CI], 0.7%-1.2%). The Kaplan-Meier estimate of ipsilateral stroke by 5 years was 4.7% (95% CI, 3.9%-5.7%).
CONCLUSIONS AND RELEVANCE
In a community-based cohort of patients with asymptomatic severe carotid stenosis who did not undergo surgical intervention, the estimated rate of ipsilateral carotid-related acute ischemic stroke was 4.7% over 5 years. These findings may inform decision-making regarding surgical and medical treatment for patients with asymptomatic severe carotid artery stenosis.
Topics: Aged; Aged, 80 and over; Asymptomatic Diseases; Carotid Stenosis; Female; Humans; Incidence; Ischemic Stroke; Male; Middle Aged; Retrospective Studies; Risk Factors; Stroke
PubMed: 35608581
DOI: 10.1001/jama.2022.4835