Carotid Intervention 1: Who Should Be Treated?

ABSTRACT

Stroke is a major cause of morbidity and mortality in the modern world. Carotid artery atheromatous disease is responsible for a significant number of these events. The effects of carotid artery disease may be prevented by appropriate treatment. All patients with known atheromatous disease should be treated with medical therapy. Despite this, some patients remain at high risk of stroke, which may be reduced by the selective use of additional therapies such as carotid endarterectomy or carotid stenting. Patients who have had recent neurological symptoms, attributable to their carotid disease, may benefit most from these additional treatments, particularly if the treatment is performed soon after the event. The operation needs to be performed with low complication rates. Some groups of patients who have been free of neurological symptoms may also benefit from these additional therapies, but these patients have a much lower inherent risk of stroke, and so the potential benefits are less. In such circumstances it is even more important that the operations are performed with minimal morbidity. Patients undergoing coronary artery bypass grafts, who also have carotid disease, are at elevated risk of stroke, and it is common practice to treat both conditions. There is no strong data to support this practice.

KEYWORDS

Carotid - stenosis - stroke - endarterectomy - stent

REFERENCES

• 1 Broderick J, Brott T, Kothari R et al.. The Greater Cincinnati/Northern Kentucky Stroke Study: preliminary first-ever and total incidence rates of strokes among blacks.  Stroke. 1998;  29 415-421
• 2 Johnston S C. Transient ischaemic attack.  N Engl J Med. 2002;  347 1687-1692
• 3 Naylor A R, Gaines P A. Carotid endarterectomy or stenting: an overview of the randomised trials. In: Wyatt MG, Watkinson AF Endovascular Intervention: Current Controversies. Shrewsbury, UK; TFM 2004: 127-133
• 4 Mackey W C, Naylor A R. Carotid artery disease: natural history and diagnosis. In: Hallet JW, Mills JW, Earnshaw JJ, Reekers JA Comprehensive Vascular and Endovascular Surgery. Edinburgh; Mosby 2004: 521-531
• 5 Chimowitz M I, Kokkinos J, Strong J et al.. The Warfarin-Aspirin Symptomatic Intracranial Disease Study.  Neurology. 1995;  45 1488-1493
• 6 Warlow C. Endarterectomy for asymptomatic carotid stenosis?.  Lancet. 1995;  345 1254-1255
• 7 Moore W S, Barnett H J, Beebe H G et al.. Guidelines for carotid endarterectomy: a multidisciplinary consensus statement from the ad hoc committee, American Heart Association.  Stroke. 1995;  26 188-201
• 8 European Carotid Surgery Trialists' Collaborative Group . MRC European Carotid Surgery Trial: interim results for symptomatic patients with severe (70-99%) or with mild (0-29%) carotid stenosis.  Lancet. 1991;  337 1235-1243
• 9 North American Carotid Endarterectomy Trial Collaborators . Beneficial effect of carotid endarterectomy in symptomatic patients with high grade stenosis.  N Engl J Med. 1991;  325 445-453
• 10 Barnett H J, Taylor D W, Eliasziw M et al.. Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis.  N Engl J Med. 1998;  339 1415-1425
• 11 Beebe H G, Clagett G P, DeWeese J A et al.. Assessing risk associated with carotid endarterectomy: a statement for health professionals by an ad hoc committee on carotid surgery standards of the Stroke Council, American Heart Association.  Circulation. 1989;  79 472-473
• 12 Donnan G A, Davis S M, Chambers B R et al.. Surgery for the prevention of stroke.  Lancet. 1998;  351 1372-1373
• 13 Hankey G J, Slattery J M, Warlow C P. Transient ischaemic attacks: which patients are at high (and low) risk of serious vascular events.  J Neurol Neurosurg Psychiatry. 1992;  55 640-652
• 14 Rothwell P M, Salinas R, Ferrando L A et al.. Does the angiographic appearance of a carotid stenosis predict the risk of stroke independently of the degree of stenosis?.  Clin Radiol. 1995;  50 830-833
• 15 Executive Committee for the Asymptomatic Carotid Atherosclerosis Study . Endarterectomy for asymptomatic carotid artery stenosis.  JAMA. 1995;  273 1421-1428
• 16 Halliday A, Mansfield A, Marro J et al.. Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomised controlled trial.  Lancet. 2004;  363 1491-1502
• 17 Thomas D. The randomised trials for asymptomatic carotid disease: how should they influence my clinical practice?. In: Naylor AR, Mackey WC Carotid Artery Surgery: A Problem Based Approach. Philadelphia; WB: Saunders 2000: 15-18
• 18 The CASSANOVA Study Group . Carotid surgery versus medical therapy in asymptomatic carotid stenosis.  Stroke. 1991;  22 1229-1235
• 19 Naylor A R. Does the modern concept of “best medical therapy” render carotid surgery obsolete?.  Eur J Vasc Endovasc Surg. 2004;  28 457-461
• 20 Yadav J S, Wholey M H, Kuntz R E et al.. Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy Investigators. Protected carotid-artery stenting versus endarterectomy in high-risk patients.  N Engl J Med. 2004;  351 1493-1501
• 21 Naylor A R, Cuffe R L, Rothwell P M, Bell P R. A systematic review of outcomes following staged and synchronous carotid endarterectomy and coronary artery bypass.  Eur J Vasc Endovasc Surg. 2003;  25 380-389
• 22 Abu-Omar Y, Cifelli A, Matthews P M, Taggart D P. The role of microembolisation in cerebral injury as defined by functional magnetic resonance imaging.  Eur J Cardiothorac Surg. 2004;  26 586-591
• 23 Naylor R, Cuffe R L, Rothwell P M, Loftus I M, Bell P R. A systematic review of outcome following synchronous carotid endarterectomy and coronary artery bypass: influence of surgical and patient variables.  Eur J Vasc Endovasc Surg. 2003;  26 230-241
• 24 Babatasi G, Massetti M, Theron J, Khayat A. Asymptomatic carotid stenosis in patients undergoing major cardiac surgery: can percutaneous carotid angioplasty be an alternative?.  Eur J Cardiothorac Surg. 1997;  11 547-553
• 25 Waigand J, Gross C M, Uhlich F et al.. Elective stenting of carotid artery stenosis in patients with severe coronary artery disease.  Eur Heart J. 1998;  19 1365-1370
• 26 Lopes D K, Mericle R A, Lanzino G, Wakhloo A K, Guterman L R, Hopkins L N. Stent placement for the treatment of occlusive atherosclerotic carotid artery disease in patients with concomitant coronary artery disease.  J Neurosurg. 2002;  96 490-496
• 27 Randall M S, McKevitt F M, Cleveland T J, Gaines P A, Venables G S. Is there any benefit from staged carotid and coronary revascularization using carotid stents? A single-center experience highlights the need for a randomized controlled trial.  Stroke. 2006;  37 435-439