European Journal of Vascular & Endovascular Surgery
Volume 40, Issue 2 , Pages 274-281 , August 2010

Transatlantic Debate. Asymptomatic Carotid Artery Stenosis – Medical Therapy Alone Versus Medical Therapy Plus Carotid Endarterectomy or Stenting

  • P.A. Schneider

      Affiliations

    • Division of Vascular Therapy, Kaiser Foundation Hospital, 3288 Moanalua Road, Honolulu, Hawaii 96819, USA
    • Corresponding Author InformationCorresponding author. Tel.: +1 808 432 8389.
    • ,
  • A.R. Naylor

      Affiliations

    • Department of Vascular Surgery, Division of Cardiovascular Sciences, Robert Kilpatrick Clinical Sciences Building, Leicester Royal Infirmary LE2 7LX, Leicester, UK
    • Tel.: +44 116 252 3252.

Received 13 May 2010 ,Accepted 13 May 2010.

References 

  1. MRC Asymptomatic Carotid Surgery Trial (ACST) Collaborative Group . Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomized controlled trial. Lancet. 2004;363:1491–1502
  2. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study . Endarterectomy for asymptomatic carotid artery stenosis. JAMA. 1995;273:1421–1428
  3. Chambers BR, Donnan G. Carotid endarterectomy for asymptomatic carotid stenosis. The Cochrane Library. 2008;(4):1–20
  4. Abbott AL. Medical (nonsurgical) intervention alone is now best for prevention of stroke associated with asymptomatic severe carotid stenosis: results of a systematic review and analysis. Stroke. 2009;40:e573–e583
  5. Spence JD. Asymptomatic carotid stenosis: criterion standard should be medical therapy. Arch Surg. 2009;144:382–383
  6. Abbott AL, Bladin CF, Levi CR, Chambers BR. What should we do with asymptomatic carotid stenosis?. Int J Stroke. 2007;2:27–39
  7. Spence DJ, Coates V, Li H, Tamayo A, Munoz C, Hackam DG, et al. Effects of intensive medical therapy on microemboli and cardiovascular risk in asymptomatic carotid stenosis. Arch Neurol. 2010;67:180–186
  8. Goessens BM, Visseren FL, Kappelle LJ, Algra A, van der Graaf Y. Asymptomatic carotid artery stenosis and the risk of new vascular events in patients with manifest arterial disease: the SMART study. Stroke. 2007;38:1470–1475
  9. Marquardt L, Geraghty OC, Mehta Z, Rothwell PM. Low risk of ipsilateral stroke in patients with asymptomatic carotid stenosis on the best medical treatment. A prospective, population-based study. Stroke. 2010;41:e11–e17
  10. Kakkos SK, Sabetai M, Tegos T, Stevens J, Dafydd T, Griffin M, et al. Silent embolic infarcts on computed tomography brain scans and the risk of ipsilateral hemispheric events in patients with asymptomatic internal carotid artery stenosis. J Vasc Surg. 2009;49:902–909
  11. Nicolaides AN, Kakkos SK, Griffin M, Sabetai M, Dhanjil S, Tegos T, et al. Asymptomatic Carotid Stenosis and Risk of Stroke (ACSRS) Study Group. Severity of asymptomatic carotid stenosis and risk of ipsilateral hemispheric ischaemic events: results from the ACSRS study. Eur J Vasc Endovasc Surg. 2005 Sep;30(3):275–284
  12. Abbott AL, Chambers BR, Stork JL, Levi CF, Donnan GA. Embolic signals and prediction of ipsilateral stroke or transient ischemic attack in asymptomatic carotid stenosis: a multicenter, prospective cohort study. Stroke. 2005;36:1128–1133
  13. Spence JD, Tamayo A, Lownie SP, Ng WP, Ferguson GG. Absence of microemboli on transcranial Doppler identifies low-risk patients with asymptomatic carotid stenosis. Stroke. 2005;36:2373–2378
  14. Naylor AR, Gaines PA, Rothwell PM. Who benefits from intervention for asymptomatic carotid stenosis: patients or professionals?. Eur J Vasc Endovasc Surg. 2009;37:625–632
  15. Great Britain and Ireland carotid endarterectomy Audit. http://www.vascularsociety.org.uk2008;
  16. Chaturvedi S, Bruno A, Feasby T, Holloway R, Benavente O, Cohen SN, et al. Carotid endarterectomy-an evidence-based review. Report of the therapeutics and technology assessment subcommittee of the American Academy of Neurology. Neurology. 2005;65:794–801
  17. Biller J, Feinberg WM, Castaldo JE, Whittemore AD, Harbaugh RE, Dempsey RJ, et al. Guidelines for carotid endarterectomy: a statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke. 1998;29:554–562
  18. Liapis CD, Bell PR, Mikhailidis D, Sivenius J, Nicolaides A, Fernandes e Fernandes G, et al. ESVS guideline Collaborators ESVS guidelines. Invasive treatment for carotid stenosis: indications, techniques. Eur J Vasc Endovasc Surg. 2009;37(4 Suppl.):1–19
  19. Hobson RW, Mackey WC, Ascher E, Murad MH, Calligaro KD, Comerota AJ, et al. Management of atherosclerotic carotid artery disease: clinical practice guidelines of the Society for Vascular Surgery. J Vasc Surg. 2008;48:480–486
  20. Sillesen H, Amarenco P, Hennerici MG, Callahan A, Goldstein LB, Zivin J, et al. on Behalf of the SPARCL Investigators Atorvastatin reduces the risk of cardiovascular events in patients with carotid atherosclerosis. A secondary analysis of the Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) Trial. Stroke. 2008;39:3297–3302
  21. Sillesen H. What does best medical therapy really mean?. Eur J Vasc Endovasc Surg. 2008;35:139–144
  22. Heart Protection Study Collaborative Group . Effects of cholesterol lowering with simvastatin on stroke and other major vascular events in 20536 people with cerebrovascular disease or other high risk conditions. Lancet. 2004;363:757–767
  23. Antithrombotic Trialists Collaboration . Collaborative meta-analysis of randomized trials of anti-platelet therapy for prevention of death, myocardial infarction and stroke in high risk patients. Br Med J. 2002;324:71–86
  24. Bhatt DL, Kieth AA, Fox MB, Berger GP, Black HR, Boden WE, et al. for the CHARISMA Investigators Clopidogrel and aspirin versus aspirin alone for the prevention of atherothrombotic events. N Engl J Med. 2006;354:
  25. McPhee JT, Schanzer A, Messina LM, Eslami MH. Carotid artery stenting has increased rates of postprocedure stroke, death, and resource utilization than does carotid endarterectomy in the United States, 2005. J Vasc Surg. 2008;48:1442–1450
  26. Goodney PP, Likosky DS, Cronenwett JL for the Vascular Study Group of Northern New England. Factors associated with stroke or death after carotid endarterectomy in Northern New England. J Vasc Surg. 2008;48:1139–1145
  27. Kang JL, Chung TK, Lancaster RT, LaMuraglia GM, Conrad MF, Cambria RP. Outcomes after carotid endarterectomy: is there a high risk population? a National Surgical Quality Improvement Program report. J Vasc Surg. 2009;49:331–339
  28. Rerkasem K, Rothwell PM. Patch angioplasty versus primary closure for carotid endarterectomy. The Cochrane Library. 2009;(4):
  29. Payne DA, Jones CI, Hayes PD, Thompson MM, London NJ, Bell PR, et al. Beneficial effects of clopidogrel combined with aspirin in reducing cerebral emboli in patients undergoing carotid endarterectomy. Circulation. 2004;109:1476–1481
  30. Molloy KJ, Thompson MM, Schwalbe EC, Bell PR, Naylor AR, Loftus IM. Comparison of levels of matrix metalloproteinases, tissue inhibitor of metalloproteinases, interleukins, and tissue necrosis factor in carotid endarterectomy specimens from patients on versus not on statins preoperatively. Am J Cardiol. 2004;94:144–146
  31. Perler BA. The effect of statin medications on perioperative and long-term outcomes following carotid endarterectomy or stenting. Semin Vasc Surg. 2007;20:252–258
  32. Brooke BS, McGirt MJ, Woodworth GF, Chang DC, Roseborough GS, Freischlag JA, et al. Preoperative statin and diuretic use influence the presentation of patients undergoing carotid endarterectomy: results of a large single-institution case-control study. J Vasc Surg. 2007;45:298–303
  33. Kadoglou NP, Sailer N, Moumtzouoglou A, Kapelouzou A, Gerasimidis T, Liapis CD. Aggressive lipid lowering is more effective than moderate lipid lowering in carotid plaque stabilization. J Vasc Surg. 2010;51:114–121
  34. Kadoglou NP, Gerasimidis T, Moumtzouoglou A, Kapelouzou A, Sailer N, Fotiadis G, et al. Intensive lipid-lowering therapy ameliorates novel calcification markers and GSM score in patients with carotid stenosis. Eur J Vasc Endovasc Surg. 2008;35:661–668
  35. CREST Executive Committee. Carotid Revascularization Endarterectomy Versus Stenting Trial. In: Annual stroke association international stroke conference 2010. San Antonio, Texas; February 24–26.
  36. Massop D, Dave R, Metzger C, Bachinsky W, Solis M, Shah R, et al. on Behalf of the SAPPHIRE Worldwide Investigators. Stenting and angioplasty with protection in patients at high-risk for endarterectomy: SAPPHIRE Worldwide Registry First 2001 patients. Catheter Cardiovasc Interv. 2009;73:129–136
  37. Lead-in results for ACT 1 Trial. www.strokecenter.org/trials/trialdetail.aspx
  38. Criado E, Fontcuberta J, Orgaz A, Flores A, Doblas M. Transcervical carotid stenting with carotid artery flow reversal: 3-year follow-up of 103 stents. J Vasc Surg. 2007;46:864–869
  39. Alvarez B, Ribo M, Maeso J, Quintana M, Alvarez-Sabin J, Matas M. Transcervical carotid stenting with flow reversal is safe in octogenarians: a preliminary safety study. J Vasc Surg. 2008;47:96–100
  40. Kelso R, Clair DG. Flow reversal for cerebral protection in carotid artery stenting: a review. Perspect Vasc Surg Endovasc Ther. 2008 Sep;20(3):282–290
  41. Sabeti S, Schlager O, Exner M, Mlekusch W, Amighi J, Dick P, et al. Progression of carotid stenosis detected by duplex ultrasonography predicts adverse outcomes in cardiovascular high-risk patients. Stroke. 2007;38:2887–2894
  42. Inzitari D, Eliasziw M, Gates P, Sharpe BL, Chan RKT, Meldrum H, et al. for the North American Symptomatic Carotid Endarterectomy Trial Collaborators The causes and risk of stroke in patients with asymptomatic internal carotid stenosis. N Engl J Med. 2000;342:1693–1700
  43. Mitka M. Improving medication adherence promises great payback, but poses tough challenge. JAMA. 2010;303:825
  44. Fukunaga S, Okada Y, Inoue T, Hattori F, Hirata K. Neuropsychological changes in patients with carotid stenosis after carotid endarterectomy. Eur Neurol. 2006;55:145–150
  45. Landgraff NC, Whitney SL, Rubinstein EN, Yonas H. Cognitive and physical performance in patients with asymptomatic carotid artery disease. J Neurol. 2010 Jan 23;[Epub ahead of print]
  46. Landgraff NC, Whitney SL, Rubinstein EN, Yonas H. Use of the physical performance test to assess preclinical disability in subjects with asymptomatic carotid artery disease. Phys Ther. 2006;86:541–548
  47. Johnston SC, O’Meara ES, Manolio TA, Lefkowitz D, O’Leary DH, Goldstein S, et al. Cognitive impairment and decline are associated with carotid artery disease in patients without clinically evident cerebrovascular disease. Ann Intern Med. 2004;140:237–247
  48. Romero JR, Beiser A, Seshadri S, Benjamin EJ, Polak JF, Vasan RS, et al. Carotid artery atherosclerosis, MRI indices of brain ischemia, aging, and cognitive impairment: the Framingham study. Stroke. 2009;40:1590–1596
  49. Abbott A. Asymptomatic carotid artery stenosis: it’s time to stop operating. Nat Clin Pract Neurol. 2008;4:4–5
  50. Brooks M. Prologue. In: Thirteen things that don’t make sense. London: Profile Books Ltd; 2010;p. 3–4
  51. Goldstein LB, Adams R, Alberts MJ, Appel LJ, Brass LM, Bushnell CD, et al. Primary Prevention of ischemic stroke. A guideline From the American Heart Association/American Stroke Association Stroke Council: cosponsored by the Atherosclerotic Peripheral Vascular Disease Interdisciplinary Working Group; Cardiovascular Nursing Council; Clinical Cardiology Council; Nutrition, Physical Activity, and Metabolism Council; and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Stroke. 2006;37:1583–1663
  52. Veith FJ, Andros G. TACIT must be funded: we must pay now or pay later. http://www.vascularweb.org/professionals/vascular_specialist/vol5/number8/newspaper_4_56642_57060.html
  53. Wholey MH, Barbato JE. Is carotid stenting justified in the asymptomatic patient? perspectives on indications for CAS. Catheter Cardiovasc Interv. 2007;69:1081–1083
  54. Moneta G. Commentary. J Vasc Surg. 2008;48:769–770
  55. Chiche L, Goulfier C. Best practice for asymptomatic carotid disease. In:  Jacobs M editors. Best practice in vascular procedures. Minerva Medica. 2010;p. 21–36Turin
  56. Hankey GJ. Asymptomatic carotid stenosis: how should it be managed?. Med J Aust. 1995;163:197–200
  57. Altman R. New York Times. October 1st 1994;
  58. Naylor AR. What is the current status of angioplasty vs endarterectomy in patients with asymptomatic carotid artery disease?. J Cardiovasc Surg. 2007;48:161–180
  59. US Preventive Services Task Force . Screening for carotid artery stenosis: US preventive services task force recommendation statement. Ann Intern Med. 2007;147:854–859
  60. Rothwell PM, Goldstein LB. Carotid endarterectomy for asymptomatic carotid stenosis: asymptomatic Carotid Surgery Trial. Stroke. 2004;5:2425–2427
  61. Naylor AR, Gaines PA, Rothwell PM. Corrigendum to: who benefits most from intervention for asymptomatic carotid stenosis: patients of professional?. Eur J Vasc Endovasc Surg. 2009;37:625–632Eur J Vasc Endovasc Surg 2009;38:657
  62. Arazi HC, Capparelli FJ, Linetzky B, Rebolledo FP, Augustovski F, Wainsztein NA. Carotid endarterectomy in asymptomatic stenosis: a decision analysis. Clin Neurol Neurosurg. 2008;110:472–479
  63. http://www.nejm.org/clinical-decisions/20080410/%20-%20commentbox
  64. Kahn J. Medical therapy alone best for asymptomatic severe carotid disease? http://www.tctmd.com/show.aspx?id=80590 [accessed 08.12. 09].
  65. Rothwell PM. Carotid stenting: more risky than endarterectomy and often no better than medical treatment alone. Lancet. 2010;375:957–959
  66. Brott T. Asymptomatic carotid disease: where do we go from here?. Vascular News. January 2010;4–6
  67. Moore WS, Young B, Baker WH, Robertson JT, Toole JF, Vescera C, et al. Surgical results: a justification of the surgeon selection process for the ACAS trial. The ACAS investigators. J Vasc Surg. 1996;23:323–328
  68. Hertzer NR. A personal view: the Asymptomatic Carotid Atherosclerosis Study results–read the label carefully. J Vasc Surg. 1996;23:167–171
  69. Young B, Moore WS, Robertson JT, Toole JF, Ernst CB, Cohen SN, et al. An analysis of peri-operative surgical mortality and morbidity in the Asymptomatic Carotid Atherosclerosis Study. Stroke. 1996;27:2216–2224
  70. Barnett HJM, Eliasziw M, Meldrum HE, Taylor DW. Do the facts and figures warrant a tenfold increase in the performance of carotid endarterectomy on asymptomatic patients?. Neurology. 1996;46:603–608
  71. Perry JR, Szalai JP, Norris JW. Consensus against both endarterectomy and routine screening for asymptomatic carotid artery stenosis: the Canadian Stroke Consortium. Arch Neurol. 1997;54:25–28
  72. Baker WH, Howard VJ, Howard G, Toole JF for the ACAS Investigators. Effect of contralateral occlusion on long term efficacy of endarterectomy in the asymptomatic Carotid Atherosclerosis Study. Stroke. 2000;31:2330–2334
  73. Inzitari D, Eliasziw M, Gates P, Sharpe BL, Chan RK, Meldrum HE. The causes and risk of stroke patients with asymptomatic internal carotid artery stenosis. N Engl J Med. 2000;342:1693–1700
  74. Kresowik TF, Bratzler DW, Karp HR, Hemann RA, Hendel ME, Kresowik RA, et al. Multistate utilization processes and outcomes of carotid endarterectomy. J Vasc Surg. 2001;33:227–235
  75. The European Stroke Initiative Executive Committee and the EUSIWriting Committee . European stroke initiative recommendations for stroke management-Update 2003. Cerebrovasc Dis. 2003;16:311–337
  76. Chaturvedi S. Should the multicenter carotid endarterectomy trials be repeated?. Arch Neurol. 2003;60:774–775
  77. Rothwell PM. ACST: which subgroups will benefit most from carotid endarterectomy?. Lancet. 2004;364:1122–1123
  78. Bunch CT, Kresowik TF. Can randomized trial outcomes for carotid endarterectomy be achieved in community wide practice?. Semin Vasc Surg. 2004;17:209–213
  79. Henriksson M, Lundgren F, Carlsson P. Cost-effectiveness of endarterectomy in patients with asymptomatic carotid artery stenosis. Br J Surg. 2008;95:715–720

☆ This paper is also being published in the Journal of Vascular Surgery 52/2 (2010) 445-54, doi's:10.1016/j.jvs.2010.05.063, 10.1016/j.jvs.2010.05.064.

PII: S1078-5884(10)00321-7

doi: 10.1016/j.ejvs.2010.05.004

European Journal of Vascular & Endovascular Surgery
Volume 40, Issue 2 , Pages 274-281 , August 2010

Article Tools