Why do guidelines recommend screening for abdominal aortic aneurysms, but not for asymptomatic carotid stenosis? A plea for a randomized controlled trial

Kosmas I Paraskevas¹, J David Spence², Dimitri P Mikhailidis³, Pier Luigi Antignani⁴, Peter Gloviczki⁵, Hans-Henning Eckstein⁶, Francesco Spinelli⁷, Francesco Stilo⁷, Luca Saba⁸, Pavel Poredos⁹, Alan Dardik¹⁰, Christos D Liapis¹¹, Armando Mansilha¹², Gianluca Faggioli¹³, Rodolfo Pini¹³, Mateja K Jezovnik¹⁴, Sherif Sultan¹⁵, Piotr Musiałek¹⁶, Guillaume Goudot¹⁷, George S Lavenson Jr¹⁸, Arkadiusz Jawien¹⁹, Aleš Blinc²⁰, Piotr Myrcha²¹, Jose Fernandes E Fernandes²², George Geroulakos²³, Stavros K Kakkos²⁴, Michael Knoflach²⁵, Robert M Proczka²⁶, Laura Capoccia²⁷, Tatjana Rundek²⁸, Alexei S Svetlikov²⁹, Mauro Silvestrini³⁰, Jean-Baptiste Ricco³¹, Alun H Davies³², Vincenzo Di Lazzaro³³, Jasjit S Suri³⁴, Gaetano Lanza³⁵, Gustav Fraedrich³⁶, Clark J Zeebregts³⁷, Andrew N Nicolaides³⁸

Affiliations

¹ Department of Vascular Surgery, Central Clinic of Athens, Athens, Greece. Electronic address: paraskevask@hotmail.com.
² Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, Western University, London, ON, Canada.
³ Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, UK.
⁴ Vascular Centre, Nuova Villa Claudia, Rome, Italy.
⁵ Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA.
⁶ Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.
⁷ Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy.
⁸ Department of Radiology, Azienda Ospedaliera Universitaria Di Cagliari, Cagliari, Italy.
⁹ Department of Vascular Disease, University Medical Centre Ljubljana, Slovenia.
¹⁰ Division of Vascular and Endovascular Surgery, Yale University School of Medicine, New Haven, CT, USA.
¹¹ Athens Vascular Research Center, Athens, Greece.
¹² Faculty of Medicine of the University of Porto, Porto, Portugal; Department of Angiology and Vascular Surgery, Hospital de S. Joao, Porto, Portugal.
¹³ Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola Malpighi, Bologna, Italy.
¹⁴ Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Centre at Houston, Houston, TX, USA.
¹⁵ Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Galway, Ireland.
¹⁶ Jagiellonian University Department of Cardiac and Vascular Diseases, John Paul II Hospital, Krakow, Poland.
¹⁷ Vascular medicine department, Georges Pompidou European hospital, APHP, Université de Paris Cité, Paris, France.
¹⁸ Department of Surgery, Uniformed Services University, Bethesda, MD, USA.
¹⁹ Department of Vascular Surgery and Angiology, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland.
²⁰ Department of Vascular Diseases, Division of Internal Medicine, University Medical Centre Ljubljana, Ljubljana, Slovenia.
²¹ Department of General and Vascular Surgery, Faculty of Medicine, Medical University of Warsaw, Warsaw, Poland.
²² Department of Vascular Surgery, University of Lisbon, Lisbon Academic Medical Center, Lisbon, Portugal.
²³ Department of Vascular Surgery, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece.
²⁴ Department of Vascular Surgery, University Hospital of Patras, Patras, Greece.
²⁵ Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria.
²⁶ 1(st) Department of Vascular Surgery, Medicover Hospital, Warsaw, Poland.
²⁷ Department of Surgery "Paride Stefanini", Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy.
²⁸ Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, USA.
²⁹ Division of Vascular and Endovascular Surgery, North-Western Scientific Clinical Center of Federal Medical Biological Agency of Russia, St. Petersburg, Russia.
³⁰ Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy.
³¹ Department of Clinical Research, University of Poitiers, CHU de Poitiers, Poitiers, France.
³² Department of Surgery and Cancer, Section of Vascular Surgery, Imperial College London, Charing Cross Hospital, London, UK.
³³ Neurology, Neurophysiology and Neurobiology Unit, Department of Medicine, Universita Campus Bio-Medico di Roma, Rome, Italy.
³⁴ Stroke Diagnostic and Monitoring Division, Atheropoint™, Roseville, CA, USA.
³⁵ Vascular Surgery Department, IRCSS Multimedica Hospital, Castellanza, Italy.
³⁶ Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria.
³⁷ Department of Surgery (Division of Vascular Surgery), University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
³⁸ Department of Surgery, University of Nicosia Medical School, Nicosia, Cyprus.

PMID: 36162523
DOI: 10.1016/j.ijcard.2022.09.045

Review

Why do guidelines recommend screening for abdominal aortic aneurysms, but not for asymptomatic carotid stenosis? A plea for a randomized controlled trial

Kosmas I Paraskevas et al. Int J Cardiol. 2023.

. 2023 Jan 15:371:406-412.

doi: 10.1016/j.ijcard.2022.09.045. Epub 2022 Sep 24.

Authors

Affiliations

¹ Department of Vascular Surgery, Central Clinic of Athens, Athens, Greece. Electronic address: paraskevask@hotmail.com.
² Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, Western University, London, ON, Canada.
³ Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, UK.
⁴ Vascular Centre, Nuova Villa Claudia, Rome, Italy.
⁵ Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA.
⁶ Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.
⁷ Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy.
⁸ Department of Radiology, Azienda Ospedaliera Universitaria Di Cagliari, Cagliari, Italy.
⁹ Department of Vascular Disease, University Medical Centre Ljubljana, Slovenia.
¹⁰ Division of Vascular and Endovascular Surgery, Yale University School of Medicine, New Haven, CT, USA.
¹¹ Athens Vascular Research Center, Athens, Greece.
¹² Faculty of Medicine of the University of Porto, Porto, Portugal; Department of Angiology and Vascular Surgery, Hospital de S. Joao, Porto, Portugal.
¹³ Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola Malpighi, Bologna, Italy.
¹⁴ Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Centre at Houston, Houston, TX, USA.
¹⁵ Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Galway, Ireland.
¹⁶ Jagiellonian University Department of Cardiac and Vascular Diseases, John Paul II Hospital, Krakow, Poland.
¹⁷ Vascular medicine department, Georges Pompidou European hospital, APHP, Université de Paris Cité, Paris, France.
¹⁸ Department of Surgery, Uniformed Services University, Bethesda, MD, USA.
¹⁹ Department of Vascular Surgery and Angiology, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland.
²⁰ Department of Vascular Diseases, Division of Internal Medicine, University Medical Centre Ljubljana, Ljubljana, Slovenia.
²¹ Department of General and Vascular Surgery, Faculty of Medicine, Medical University of Warsaw, Warsaw, Poland.
²² Department of Vascular Surgery, University of Lisbon, Lisbon Academic Medical Center, Lisbon, Portugal.
²³ Department of Vascular Surgery, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece.
²⁴ Department of Vascular Surgery, University Hospital of Patras, Patras, Greece.
²⁵ Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria.
²⁶ 1(st) Department of Vascular Surgery, Medicover Hospital, Warsaw, Poland.
²⁷ Department of Surgery "Paride Stefanini", Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy.
²⁸ Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, USA.
²⁹ Division of Vascular and Endovascular Surgery, North-Western Scientific Clinical Center of Federal Medical Biological Agency of Russia, St. Petersburg, Russia.
³⁰ Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy.
³¹ Department of Clinical Research, University of Poitiers, CHU de Poitiers, Poitiers, France.
³² Department of Surgery and Cancer, Section of Vascular Surgery, Imperial College London, Charing Cross Hospital, London, UK.
³³ Neurology, Neurophysiology and Neurobiology Unit, Department of Medicine, Universita Campus Bio-Medico di Roma, Rome, Italy.
³⁴ Stroke Diagnostic and Monitoring Division, Atheropoint™, Roseville, CA, USA.
³⁵ Vascular Surgery Department, IRCSS Multimedica Hospital, Castellanza, Italy.
³⁶ Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria.
³⁷ Department of Surgery (Division of Vascular Surgery), University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
³⁸ Department of Surgery, University of Nicosia Medical School, Nicosia, Cyprus.

PMID: 36162523
DOI: 10.1016/j.ijcard.2022.09.045

Abstract

Background: Current guidelines do not recommend screening for asymptomatic carotid artery stenosis (AsxCS). The rationale behind this recommendation is that detection of AsxCS may lead to an unnecessary carotid intervention. In contrast, screening for abdominal aortic aneurysms is strongly recommended.

Methods: A critical analysis of the literature was performed to evaluate the implications of detecting AsxCS.

Results: Patients with AsxCS are at high risk for future stroke, myocardial infarction and vascular death. Population-wide screening for AsxCS should not be recommended. Additionally, screening of high-risk individuals for AsxCS with the purpose of identifying candidates for a carotid intervention is inappropriate. Instead, selective screening for AsxCS should be considered and should be viewed as an opportunity to identify individuals at high risk for atherosclerotic cardiovascular disease and future cardiovascular events for the timely initiation of intensive medical therapy and risk factor modification.

Conclusions: Although mass screening should not be recommended, there are several arguments suggesting that selective screening for AsxCS should be considered. The rationale supporting such selective screening is to optimize risk factor control and to initiate intensive medical therapy for prevention of future cardiovascular events, rather than to identify candidates for an intervention.

Keywords: Asymptomatic carotid atherosclerosis; Carotid plaque burden; Carotid stenosis; Guidelines; Screening; Stroke.

PubMed Disclaimer

Conflict of interest statement

Declaration of Competing Interest All authors are members of the Faculty Advocating Collaborative and Thoughtful Carotid Artery Treatments (FACTCATS; available at www.FACTCATS.org) with the shared goal of optimizing stroke prevention. The views of particular FACTCATS do not necessarily reflect the views of other FACTCATS.

Comment in

Screening for asymptomatic carotid stenosis in patients with non-valvular atrial fibrillation.
Paraskevas KI, Eckstein HH, Mansilha A, Ricco JB, Geroulakos G, Di Lazzaro V, Rundek T, Lanza G, Fraedrich G, Svetlikov AS, Suri JS, Zeebregts CJ, Davies AH, Capoccia L, Proczka RM, Myrcha P, Antignani PL, Fernandes E Fernandes J, Spence JD, Dardik A, Jezovnik MK, Knoflach M, Lavenson GS Jr, Kakkos SK, Jawien A, Silvestrini M, Blinc A, Spinelli F, Stilo F, Musiałek P, Sultan S, Goudot G, Liapis CD, Saba L, Faggioli G, Pini R, Poredos P, Mikhailidis DP, Gloviczki P, Nicolaides AN. Paraskevas KI, et al. Int J Cardiol. 2023 Feb 1;372:120-121. doi: 10.1016/j.ijcard.2022.11.037. Epub 2022 Nov 23. Int J Cardiol. 2023. PMID: 36435330 No abstract available.
Could carotid screening cause more harm than good?
Zhang W, Wang F. Zhang W, et al. Int J Cardiol. 2023 Mar 1;374:115. doi: 10.1016/j.ijcard.2022.12.038. Epub 2022 Dec 21. Int J Cardiol. 2023. PMID: 36565955 No abstract available.
Clarifying the rationale supporting selective screening for asymptomatic carotid artery stenosis.
Paraskevas KI, Nicolaides AN, Spence JD, Mikhailidis DP, Lanza G, Liapis CD, Goudot G, Faggioli G, Pini R, Musiałek P, Suri JS, Silvestrini M, Fernandes E Fernandes J, Eckstein HH, Jawien A, Spinelli F, Stilo F, Myrcha P, Rundek T, Kakkos SK, Di Lazzaro V, Svetlikov A, Antignani PL, Poredos P, Saba L, Jezovnik MK, Blinc A, Sultan S, Knoflach M, Jezovnik MK, Capoccia L, Proczka RM, Fraedrich G, Zeebregts CJ, Davies AH, Geroulakos G, Ricco JB, Mansilha A, Dardik A, Gloviczki P. Paraskevas KI, et al. Int J Cardiol. 2023 Apr 1;376:174-175. doi: 10.1016/j.ijcard.2023.01.028. Epub 2023 Jan 18. Int J Cardiol. 2023. PMID: 36681248 No abstract available.

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Why do guidelines recommend screening for abdominal aortic aneurysms, but not for asymptomatic carotid stenosis? A plea for a randomized controlled trial

Affiliations

Why do guidelines recommend screening for abdominal aortic aneurysms, but not for asymptomatic carotid stenosis? A plea for a randomized controlled trial

Authors

Affiliations

Abstract

Conflict of interest statement

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