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Sunday, June 19, 2016
Sunday, June 5, 2016
Management of Asymptomatic Carotid Artery Stenosis
Introduction
Asymptomatic stenosis of the carotid artery is not an
uncommon finding encountered by many doctors in clinical practice.
The common question that comes up is
What is the management of these patients?
Should they undergo carotid revascularization surgery?
Current guidelines recommend revascularization in most
patients with severe asymptomatic carotid artery stenosis. However, these
guidelines are based on older studies that do not reflect the changing natural
history of asymptomatic carotid artery stenosis with current optimal medical
management.
Conventional
treatment
Current recommendations for revascularization for
asymptomatic carotid artery stenosis are predominantly based on two landmark
studies performed in the 1990s.
The Asymptomatic Carotid Artery Study (ACAS) was a
well-conducted study that assessed carotid endarterectomy (CEA) in asymptomatic
carotid artery stenosis (>60%) for stroke prevention. The study was halted
because of a projected safety favoring carotid endarterectomy (CEA). The perioperative
stroke rate was 2.3%. The five-year projected rate of ipsilateral stroke was
11% for the medical group versus 5.1% for the surgical group.
In the Asymptomatic Carotid Surgery Trial (ACST), the 30-day
risk of stroke or death was 3.1%. The five-year rates were 6.4% for CEA and
11.7% for medical therapy arm.
However, medical therapy in these trials was not up to
current standards, with only a minority of patients receiving lipid-lowering
therapy (Statins) and blood pressure (BP) was also significantly higher than
today's standards.
Evolving Natural
History of Asymptomatic Carotid Artery Stenosis
Recent evidence suggests that the natural history of
asymptomatic carotid artery stenosis has improved remarkably, and the
risk-benefit analysis of revascularization will need to be re-evaluated.
Current optimal medical management consists of high-dose statin drugs, optimal
BP control, smoking cessation, antiplatelet therapy (generally aspirin alone),
optimal diabetes control and other lifestyle changes. Hence, the annual risk of
stroke with current OMT is likely <1%.
Who is a
"High-Risk" Patient?
The reality is that the majority of patients with
asymptomatic carotid artery stenosis will never become symptomatic and may
undergo unnecessary procedures if these studies do show benefit of
endarterectomy or stenting
Clinical
Features
There are few clinical predictors of increased stroke risk
in asymptomatic carotid artery stenosis. Certain clinical characteristics, such
as male sex, current smoking, poorly controlled hypertension, and history of
contralateral transient ischemic attack (TIA)/stroke impart a higher risk of
future stroke. However these are too non-specific to serve as useful guides for
deciding about revascularization.
Stenosis
Severity
Patients with 50-69% stenosis had a lower risk compared to
those with 70-89% and 90-99% stenosis. However, stenosis severity alone is not
a strong enough predictor to be used alone in decision making.
Progression
of Stenosis
Progression of stenosis on periodic examination has been
shown to impart at least twice the risk of stroke in patients.
Plaque
Characteristics
Using ultrasound, atherosclerotic plaques can be
characterized based on their surface irregularity, ulcerations, echolucency and
gray-scale values. Studies show that patients with predominantly echolucent,
lipid-rich plaque have significantly higher stroke risk (3%) than those with
mostly echodense, fibrotic plaque (0.8-0.4%). Ulceration on plaque surface
detected by three-dimensional ultrasound has also been shown to identify
high-risk subjects. Magnetic resonance imaging (MRI) has also been used to
detect the presence of intraplaque hemorrhage as indicative of a high-risk
plaque. Intraplaque hemorrhage detected by MRI is associated with an increased
risk of cerebrovascular events
Silent
Emboli Detection
Since both progressive stenosis and high-risk imaging
features identify unstable plaque more prone to atheroembolic events, another
way to identify patients at risk is to assess for active silent emboli or
evidence of prior asymptomatic cerebral emboli using transcranial doppler
study. However, most patients with these signals did remain stroke free at
three years, and thus, this test lacks the specificity for stand-alone clinical
use.
Silent Embolic Infarcts on Computed Tomography (CT) or MRI
Presence of ipsilateral silent embolic infarcts on
neuroimaging may be predictive of increased risk of ipsilateral stroke.
Reduced
Cerebrovascular Reserve
In patients with severe ipsilateral carotid stenosis, the
presence of an incomplete circle of Willis or presence of intracranial or
contralateral occlusive disease can reduce cerebral perfusion pressure.
Cerebrovascular reserve in such patients can be assessed using TCD velocity
measurements in response to acetazolamide or breathing 5% CO2.
Elderly
The elderly (especially those over 80 years of age) is a
group in which the benefit of revascularization for asymptomatic carotid artery
stenosis is most controversial because However, age cannot be an absolute
contraindication with increasing life expectancy of the overall population;
certainly in carefully selected patients, excellent outcomes after both CEA
(Carotid Endarterectomy) and CAS (Carotid Artery Stenting) have been
demonstrated. Overall CEA has more favorable outcomes for those over 70 years
of age and CAS for those under 70 years of age.
Conclusions
and Recommendations for Clinical Practice
Both medical and surgical management arms of asymptomatic
carotid artery stenosis are rapidly evolving and will continue to result in
decreased stroke risk.
- We recommend that for asymptomatic carotid artery stenosis
patients (even those with >80%) stenosis there is enough evidence for a more
conservative approach and decisions regarding revascularization should be made
after discussing the stroke risk with the patients.
- Serial ultrasounds should be performed and revascularization
offered to those with >70% stenosis with evidence of progression of stenosis
severity.
- All patients with asymptomatic carotid artery stenosis
should be on Optimal Medical Management.
- For the very elderly (>80 years) and life expectancy less
than five years, a conservative approach is most reasonable in most situations.
- Carotid Endarterectomy remains the gold-standard for
revascularization of carotid stenosis. Carotid Artery Stenting should be
considered in patients with high risk of surgery from associated cardiac
co-morbidity.
- Individual patient and anatomic risks for CEA and CAS are different
and should be considered and a multi-specialty approach should be followed.
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