Diagnosis, Treatment and Follow-up in Extracranial Carotid Stenosis

Association between hospital ownership and patient selection, management, and outcomes after carotid endarterectomy or carotid artery stenting : - Secondary data analysis of the Bavarian statutory quality assurance database

BACKGROUND

This study analyses the association between hospital ownership and patient selection, treatment, and outcome of carotid endarterectomy (CEA) or carotid artery stenting (CAS).

METHODS

The analysis is based on the Bavarian subset of the nationwide German statutory quality assurance database. All patients receiving CEA or CAS for carotid artery stenosis between 2014 and 2018 were included. Hospitals were subdivided into four groups: university hospitals, public hospitals, hospitals owned by charitable organizations, and private hospitals. The primary outcome was any stroke or death until discharge from hospital. Research was funded by Germany's Federal Joint Committee Innovation Fund (01VSF19016 ISAR-IQ).

RESULTS

In total, 22,446 patients were included. The majority of patients were treated in public hospitals (62%), followed by private hospitals (17%), university hospitals (16%), and hospitals under charitable ownership (6%). Two thirds of patients were male (68%), and the median age was 72 years. CAS was most often applied in university hospitals (25%) and most rarely used in private hospitals (9%). Compared to university hospitals, patients in private hospitals were more likely asymptomatic (65% vs. 49%). In asymptomatic patients, the risk of stroke or death was 1.3% in university hospitals, 1.5% in public hospitals, 1.0% in hospitals of charitable owners, and 1.2% in private hospitals. In symptomatic patients, these figures were 3.0%, 2.5%, 3.4%, and 1.2% respectively. Univariate analysis revealed no statistically significant differences between hospital groups. In the multivariable analysis, compared to university hospitals, the odds ratio of stroke or death in asymptomatic patients treated by CEA was significantly lower in charitable hospitals (OR 0.19 [95%-CI 0.07-0.56, p = 0.002]) and private hospitals (OR 0.47 [95%-CI 0.23-0.98, p = 0.043]). In symptomatic patients (elective treatment, CEA), patients treated in private or public hospitals showed a significantly lower odds ratio compared to university hospitals (0.36 [95%-CI 0.17-0.72, p = 0.004] and 0.65 [95%-CI 0.42-1.00, p = 0.048], respectively).

CONCLUSIONS

Hospital ownership was related to patient selection and treatment, but not generally to outcomes. The lower risk of stroke or death in the subgroup of electively treated patients in private hospitals might be due to the right timing, the choice of treatment modality or actually to better structural and process quality.

Radiation Dose and Fluoroscopy Time of Extracranial Carotid Artery Stenting : Elective vs. Emergency Treatment Including Combined Mechanical Thrombectomy in Tandem Occlusion

PURPOSE

Fluoroscopically guided endovascular carotid artery stenting (CAS) of extracranial carotid stenosis (ECS) is a reasonable alternative to carotid endarterectomy in selected patients. Diagnostic reference levels (DRL) for this common neurointervention have not yet been defined and respective literature data are sparse. We provide detailed dosimetrics for useful expansion of the DRL catalogue.

METHODS

A retrospective single-center study of patients undergoing CAS between 2013 and 2021. We analyzed dose area product (DAP) and fluoroscopy time considering the following parameters: indications for CAS, semielective/elective versus emergency including additional mechanical thrombectomy (MT) in extracranial/intracranial tandem occlusion, etiology of ECS (atherosclerotic vs. radiation-induced), periprocedural features, e.g., number of applied stents, percutaneous transluminal angioplasty (PTA) and MT maneuvers, and dose protocol. Local DRL was defined as 75% percentile of the DAP distribution.

RESULTS

A total of 102 patients were included (semielective/elective CAS n = 75, emergency CAS n = 8, CAS + MT n = 19). Total median DAP was 78.2 Gy cm2 (DRL 117 Gy cm2). Lowest and highest median dosimetry values were documented for semielective/elective CAS and CAS + MT (DAP 49.1 vs. 146.8 Gy cm2, fluoroscopy time 27.1 vs. 43.8 min; p < 0.005), respectively. Dosimetrics were significantly lower in patients undergoing 0-1 PTA maneuvers compared to ≥ 2 maneuvers (p < 0.05). Etiology of ECS, number of stents and MT maneuvers had no significant impact on dosimetry values (p > 0.05). A low-dose protocol yielded a 33% reduction of DAP.

CONCLUSION

This CAS study suggests novel local DRLs for both elective and emergency cases with or without intracranial MT. A dedicated low-dose protocol was suitable for substantial reduction of radiation dose.

Carotid artery interventions - endarterectomy versus stenting

Current management of patients with carotid artery stenosis is based on well-established guidelines, including surgical procedures - carotid endarterectomy (CEA) and endovascular carotid artery stenting (CAS) - and optimal medical treatment alone. Outcomes in the postprocedural period after CAS and CEA are similar, suggesting strong clinical durability for both treatments. Recent advances, which include the emergence of novel endovascular treatment tools and techniques, combined with more recent randomised trial data shed new light on optimal patient selection and treatment in contemporary practice. Improved, modern technologies including enhanced embolic protection devices and dual-layered micromesh stents yield better outcomes and should result in further improvements in CAS. In centres of excellence, nowadays, the majority of patients with severe carotid artery stenosis can be successfully treated with either CEA or CAS.

What are the benefits and drawbacks of statins in carotid artery disease? A perspective review

INTRODUCTION

The prevalence of carotid artery stenosis in the general population is approximately 3%, but approximately 20% among people with acute ischemic stroke. Statins are recommended by multiple international guidelines as the drug of choice for lipid control in people with asymptomatic or symptomatic carotid artery stenosis due to their lipid-lowering and other pleiotropic effects.

AREAS COVERED

This review discusses the guidelines for statin usage as a cornerstone in the prevention and management of atherosclerotic carotid artery disease and the impact of statins on stroke incidence and mortality. Statin side effects, alternative therapy, and genetic polymorphisms are reviewed.

EXPERT OPINION

Statin therapy is associated with a decreased incidence of stroke and mortality as well as improved outcomes for patients treated with carotid revascularization. Statins are a safe and effective class of medications, but the initiation of therapy warrants close monitoring to avoid rare and potentially serious side effects. Lack of clinical efficacy or the presence of side effects suggests a need for treatment with an alternative therapy such as PCSK9 inhibitors. Understanding the interplay between the mechanisms of statins and PCSK9 inhibition therapies will allow optimal benefits while minimizing risks. Future research into genetic polymorphisms may improve patient selection for personalized therapy.

Carotid Artery Stenting for Asymptomatic Carotid Stenosis: What We Need to Know for Treatment Decision

A clinical decision on the treatment of asymptomatic carotid stenosis is challenging, unlike symptomatic carotid stenosis. Carotid artery stenting (CAS) has been recommended as an alternative to carotid endarterectomy (CEA) based on the finding that the efficacy and safety of CAS were comparable to CEA in randomized trials. However, in some countries, CAS is often performed more frequently than CEA for asymptomatic carotid stenosis. Moreover, it has been recently reported that CAS is not superior to the best medical treatment in asymptomatic carotid stenosis. Due to these recent changes, the role of CAS in asymptomatic carotid stenosis should be revisited. When determining the treatment for asymptomatic carotid stenosis, one should consider several clinical factors including stenosis degree, patient life expectancy, stroke risk by medical treatment, availability of a vascular surgeon, high risk for CEA or CAS, and insurance coverage. This review aimed to present and pragmatically organize the information that is necessary for a clinical decision on CAS in asymptomatic carotid stenosis. In conclusion, although the traditional benefit of CAS is being revisited recently, it seems too early to conclude that CAS is no longer beneficial under intense and systemic medical treatment. Instead, a treatment strategy with CAS should evolve to select eligible or medically high-risk patients more precisely.

[Important recommendations of the German-Austrian S3 guidelines on management of extracranial carotid artery stenosis]

BACKGROUND

Lesions of the extracranial carotid artery are the cause of 10-15 % of all cases of cerebral ischemia. The aims of the updated S3 guidelines are evidence-based and consensus-based recommendations for action on comprehensive care of patients with extracranial carotid stenosis in Germany and Austria.

METHODS

A systematic literature search (1990-2019) and methodical assessment of existing guidelines and systematic reviews were carried out. Consensus answers to 37 key questions with evidence-based recommendations.

RESULTS

The prevalence of extracranial carotid stenosis is approximately 4% and increases after the age of 65 years. The most important examination method is duplex sonography. Randomized controlled studies (RCT) have shown that carotid endarterectomy (CEA) of an asymptomatic 60-99% carotid artery stenosis reduces the absolute risk of stroke (absolute risk reduction, ARR) within 5 years in comparison to drug treatment alone by 4.1%. Due to an improved pharmaceutical prevention of arteriosclerosis, the S3 guidelines recommend a prophylactic CEA of a 60-99% stenosis only for patients without an increased surgical risk. Additionally, one or more clinical or imaging results should be present, which indicate an increased risk of carotid-related stroke in the follow-up. For medium-grade (50-69 %) and high-grade (70-99 %) symptomatic stenoses the ARRs after 5 years are 4.6% and 15.6%, respectively. Systematic reviews of RCTs have shown that CEA is associated with a ca. 50% lower periprocedural risk of stroke compared to carotid artery stenting (CAS). There are no differences in the long-term course. The CEA is recommended for high-grade asymptomatic, medium-grade and high-grade symptomatic carotid stenosis as a standard procedure, alternatively CAS can be considered. For both procedures the periprocedural stroke rate/mortality during hospitalization should be a maximum of 2% (asymptomatic stenosis) or 4% (symptomatic stenosis).

CONCLUSION

Both CEA and CAS necessitate a critical evaluation of the indications and strict quality criteria. Future studies should evaluate even better selection criteria for an individual, optimal, conservative, operative or endovascular treatment.

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

OBJECTIVES

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 is to reconcile the conflicting views on the topic.

MATERIALS AND METHODS

A literature review was performed with a focus on data from recent studies.

RESULTS

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.

CONCLUSIONS

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.

European Stroke Organisation guideline on endarterectomy and stenting for carotid artery stenosis

Atherosclerotic stenosis of the internal carotid artery is an important cause of stroke. The aim of this guideline is to analyse the evidence pertaining to medical, surgical and endovascular treatment of patients with carotid stenosis. These guidelines were developed based on the ESO standard operating procedure and followed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. The working group identified relevant questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and wrote recommendations. Based on moderate quality evidence, we recommend carotid endarterectomy (CEA) in patients with ≥60-99% asymptomatic carotid stenosis considered to be at increased risk of stroke on best medical treatment (BMT) alone. We also recommend CEA for patients with ≥70-99% symptomatic stenosis, and we suggest CEA for patients with 50-69% symptomatic stenosis. Based on high quality evidence, we recommend CEA should be performed early, ideally within two weeks of the last retinal or cerebral ischaemic event in patients with ≥50-99% symptomatic stenosis. Based on low quality evidence, carotid artery stenting (CAS) may be considered in patients < 70 years old with symptomatic ≥50-99% carotid stenosis. Several randomised trials supporting these recommendations were started decades ago, and BMT, CEA and CAS have evolved since. The results of another large trial comparing outcomes after CAS versus CEA in patients with asymptomatic stenosis are anticipated in the near future. Further trials are needed to reassess the benefits of carotid revascularisation in combination with modern BMT in subgroups of patients with carotid stenosis.