The diagnosis, treatment and follow-up of extracranial carotid stenosis

Abstract

Background: Extracranial atherosclerotic lesions of the carotid bifurcation cause 10% to 20% of all cases of cerebral ischemia. Until now, there have been no comprehensive evidence- and consensus-based recommendations for the management of patients with extracranial carotid stenosis in Germany and Austria.

Methods: The literature was systematically searched for pertinent publications (1990-2011). On the basis of 182 randomized clinical trials (RCTs) and 308 systematic reviews, 30 key questions were answered and evidence-based recommendations were issued.

Results: The prevalence of extracranial carotid stenosis is more than 5% from age 65 onward. Men are affected twice as frequently as women. The most important diagnostic technique is Doppler- and color-coded duplex ultrasonography. RCTs have shown that the treatment of high-grade asymptomatic carotid stenosis with carotid endarterectomy (CEA) can lower the 5-year risk of stroke from 11% to 5%. Intensive conservative treatment may lower the stroke risk still further. Moreover, RCTs have shown that CEA for symptomatic 50% to 99% carotid stenosis lowers the 5-year stroke risk by 5% to 16%. Meta-analyses of the 13 available RCTs comparing carotid artery stenting (CAS) with CEA have shown that CAS is associated with a 2% to 2.5% higher risk of periprocedural stroke or death and with a 0.5% to 1% lower risk of periprocedural myocardial infarction. If no particular surgical risk factors are present, CEA is the standard treatment for high-grade carotid stenosis. CAS may be considered as an alternative to CEA if the rate of procedure-related stroke or death can be kept below 3% or 6% for asymptomatic and symptomatic stenosis, respectively.

Conclusion: Further studies are needed so that better selection criteria can be developed for individually tailored treatment.

Figure 1

Literature-searching procedure GMS, German Medical Science database; LWW, Lippincott Williams & Wilkins publisher’s database; MA, systematic review with metaanalysis; NHS, National Institute for Health Research; RCT, randomized controlled trial; SR, systematic review; CEA, carotid endarterectomy; CAS, carotid stenting

Figure 2

Angiographic quantifying methods for carotid stenosis: NASCET, (B–A)/B × 100%; ECST, (C–A)/C × 100%. The former is the distal degree of stenosis, the latter is the proximal degree of stenosis.

Figure 3

Forest plot for estimation of the procedural risk for the combined endpoint “any procedure-related stroke or death” OR, odds ratio; CI, confidence interval; CEA, carotid endarterectomy; CAS, carotid stenting. From: Economopoulos KP, Sergentanis TN, Tsivgoulis G, Mariolis AD, Stefanadis C: Carotid artery stenting versus carotid endarterectomy: a comprehensive meta-analysis of short-term and long-term outcomes. Stroke; a Journal of Cerebral Circulation. 2011; 42: 687–692. Reprinted with the permission of Wolters Kluwer Health (30).