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

Paraskevas, Kosmas I.;Mikhailidis, Dimitri P.;Antignani, Pier L.;Baradaran, Hediyeh;Bokkers, Reinoud P.H.;Cambria, Richard P.;Dardik, Alan;Davies, Alun H.;Eckstein, Hans Henning;Faggioli, Gianluca;Fernandes E Fernandes, José;Fraedrich, Gustav;Geroulakos, George;Gloviczki, Peter;Golledge, Jonathan;Gupta, Ajay;Jezovnik, Mateja K.;Kakkos, Stavros K.;Katsiki, Niki;Knoflach, Michael;Kooi, M. Eline;Lanza, Gaetano;Liapis, Christos D.;Loftus, Ian M.;Mansilha, Armando;Millon, Antoine;Nicolaides, Andrew N.;Pini, Rodolfo;Poredos, Pavel;Ricco, Jean Baptiste;Riles, Thomas S.;Ringleb, Peter Arthur;Rundek, Tatjana;Saba, Luca;Schlachetzki, Felix;Silvestrini, Mauro;Spinelli, Francesco;Stilo, Francesco;Sultan, Sherif;Suri, Jasjit S.;Zeebregts, Clark J.;Chaturvedi, Seemant

Jonathan Golledge

Abstract

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.

Journal

International Angiology

Publication Name

N/A

Volume

ISBN/ISSN

1827-1839

Edition

N/A

Issue

Pages Count

Location

N/A

Publisher

Edizioni Minerva Medica

Publisher Url

N/A

Publisher Location

N/A

Publish Date

N/A

Url

N/A

Date

N/A

EISSN

N/A

DOI

10.23736/S0392-9590.21.04825-2