Mortality risk stratification in patients with asymptomatic carotid stenosis

Carotid Artery Stenosis: A Look Into the Diagnostic and Management Strategies, and Related Complications

Carotid stenosis (CS) is a buildup of atherosclerotic plaque within the artery leading to a wide range of symptoms, from mild symptoms, including blurred vision and confusion, to much more life-threatening presentations, including paralysis due to stroke. The presentation is insidious, with symptoms exhibiting predominantly at severe stenosis; hence the emphasis is placed on the importance of early diagnosis, treatment, and lifestyle modifications. CS is seen undergoing almost the same pathogenesis of any atherosclerotic plaque formation, from endothelial damage of the artery lumen to the formation of a fibrous cap with a foam cell, lipid-filled core. The findings of our review article were consistent with the recent literature, depicting that comorbid hypertension, diabetes, and chronic kidney disease (CKD), and lifestyle aspects, including smoking and diet, played the most salient role in plaque development. Among several imaging modalities, duplex ultrasound (DUS) imaging is the widely preferred method in clinical practice. Carotid endarterectomy (CEA) and carotid stenting are the primarily advocated procedures for symptomatic severe stenosis, with similar long-term outcomes. Although, earlier clinical trials showed promising results in mitigating the risk of stroke among asymptomatic severe CS with surgical intervention. However, recent advancements have shifted the focus to medical management alone due to comparable results among the asymptomatic population. Both surgical and medical regimens are beneficial in treating patients, but it is still an ongoing debate as to which is predominantly superior. The currently advancing trials and research will help elucidate definitive guidelines. However, the massive impact of lifestyle modifications advocates some degree of individualized multidisciplinary management strategies.

Risk Stratification and Management of Extracranial Carotid Artery Disease

Stroke is the fifth leading cause of death in the United States and is a leading cause of disability. Extracranial internal carotid artery stenosis is a major cause of ischemic stroke, as it is estimated to cause 8% to 15% of ischemic strokes. It is critical to improve our strategies for stroke prevention and treatment in order to reduce the burden of this disease. Herein, we review approaches for the diagnosis and risk stratification of carotid artery disease as well as interventional strategies for the prevention and treatment of strokes caused by carotid artery disease.

[Asymptomatic carotid stenosis: What is new?]

In industrialized countries, stroke is still the most common disease that leads to permanent disability. Of the 250 000 strokes that occur annually in Germany, in about 80 % are cerebral ischemia. Approximately 15 % of these ischemias are caused by lesions of the extracranial internal carotid artery, so optimal treatment of extracranial carotid stenosis is essential 1. This continues to be the subject of a controversial debate, as optimized drug therapy has led to a significant reduction in risk.In 2020, the multidisciplinary S3 guideline for the management of extracranial carotid stenoses was updated. In the following, current aspects and new recommendations for asymptomatic carotid stenosis are presented and important innovations of the guideline are explained.

Trends and controversies in carotid artery stenosis treatment

Despite the completion of several multi-center trials, the management of carotid stenosis remains in flux. Key questions include the role of intensive medical management in the treatment of asymptomatic carotid stenosis. In addition, identification of patients with symptomatic stenosis who will most benefit from carotid revascularization remains a priority. The role of newer imaging techniques such as carotid plaque analysis with magnetic resonance imaging is also challenging current treatment paradigms. These topics are explored in this topical update.

[New possibilities of antithrombotic therapy improving prognosis in patients with stenosing atherosclerosis of carotid arteries]

The purpose of the COMPASS (Cardiovascular Outcomes for People Using Anticoagulation Strategies) trial was to evaluate a regimen of a two-way impact on thrombus formation in patients presenting with ischaemic heart disease and peripheral artery diseases. The study included a total of 1,919 patients with stenosis of carotid arteries and 1,032 patients with a history of stroke. Many patients with disease of peripheral arteries (including carotid arteries) enrolled into the COMPASS trial appeared to have additional risk factors for stroke such as, for instance, current or former smoking, diabetes mellitus, or ischaemic heart disease. An additionally carried out analysis for strokes revealed that supplementing rivaroxaban at a dose of 2.5 mg twice daily to acetylsalicylic acid decreased the risk for the development of ischaemic stroke by 49% (p<0.001), without increasing the risk for haemorrhagic transformation on the background of combined therapy (HR=0.35; 95% CI: 0.13-0.99; p=0.04), whereas the risk for haemorrhagic strokes remained at a low level and did not differ between the groups (HR=1.49; 95% CI: 0.67-3.31; p=0.33). The composite risk for major ischaemic and haemorrhagic events was significantly lower in the group of combined therapy. Adding rivaroxaban to acetylsalicylic acid appeared to result in a decrease in the risk of all-cause mortality in patients with ischaemic heart disease and peripheral artery disease by 18%. Thus, the addition of rivaroxaban at a dose of 2.5 mg twice daily to acetylsalicylic acid made it possible to decrease the risks of both primary and secondary strokes, and hence may be considered in patients with significant stenoses of carotid arteries for primary prevention, whereas in patients with endured ischaemic stroke - for secondary prevention, as well as after open endovascular reconstructive operations on carotid arteries.