Management of Patients with Asymptomatic and Symptomatic Carotid Artery Disease: Update on Anti-Thrombotic Therapy

AbstractThe most common causes of ischaemic stroke are represented by carotid artery atherosclerotic disease (CAAD) and atrial fibrillation. While oral anticoagulants substantially reduce the incidence of thromboembolic stroke (< 1%/year), the rate of ischaemic stroke and other cardiovascular disease events in patients with CAAD remains high, ranging from 8.4 to 18.1 events per 100 patient-years. Similar to any other atherosclerotic disease, anti-thrombotic therapies are proposed for CAAD to reduce stroke and other cardiovascular events. The 2017 European Society of Cardiology (ESC)/European Society for Vascular Surgery (ESVS) guidelines recommend for patients with asymptomatic CAAD ≥60% the use of aspirin 75 to 100 mg once daily or clopidogrel 75 mg once daily at the exception of patient at very high bleeding risk. For patients with symptomatic CAAD ≥50%, the use of aspirin 75 to 100 mg once daily or clopidogrel 75 mg once daily is recommended. New perspectives for anti-thrombotic therapy for the treatment of patients with CAAD come from the novel dual pathway strategy combining a low-dose anticoagulant (i.e. rivaroxaban) and aspirin that may help reduce long-term ischaemic complications in patients with CAAD. This review summarizes current evidence and recommendations for the anti-thrombotic management of patients with symptomatic or asymptomatic CAAD or those undergoing carotid revascularization.

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Assessment of carotid plaque morphology in symptomatic carotid artery disease on ultrasound for predicting the increased ischaemic stroke risk – A systematic review

International Journal of Surgery ◽

10.1016/j.ijsu.2016.08.493 ◽

2016 ◽

Vol 36 ◽

pp. S131

Author(s):

R. Goel ◽

M. Goel ◽

M.E. O'Donnell ◽

H. Al-Khaffaf

Keyword(s):

Systematic Review ◽

Carotid Artery ◽

Ischaemic Stroke ◽

Carotid Plaque ◽

Stroke Risk ◽

Carotid Artery Disease ◽

Plaque Morphology ◽

Symptomatic Carotid ◽

Artery Disease

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Evaluation of haemodynamic impairment and collateral flow in symptomatic carotid artery disease using arterial spin labelling MRI

Aktuelle Neurologie ◽

10.1055/s-2005-919686 ◽

2005 ◽

Vol 32 (S 4) ◽

Author(s):

R Kern ◽

M Günther ◽

F Sallustio ◽

K Szabo ◽

M Griebe ◽

...

Keyword(s):

Carotid Artery ◽

Carotid Artery Disease ◽

Arterial Spin Labelling ◽

Collateral Flow ◽

Symptomatic Carotid ◽

Artery Disease ◽

Spin Labelling

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Concomitant Surgical Treatment of Symptomatic Carotid Artery Disease With a Coexisting Shamblin I Carotid Body Tumor

Vascular and Endovascular Surgery ◽

10.1177/1538574416689430 ◽

2017 ◽

Vol 51 (2) ◽

pp. 103-107 ◽

Cited By ~ 2

Author(s):

Carlos A. Hinojosa ◽

Javier E. Anaya-Ayala ◽

Hugo Laparra-Escareno ◽

Adriana Torres-Machorro ◽

Rene Lizola ◽

...

Keyword(s):

Carotid Artery ◽

Carotid Body ◽

Carotid Artery Disease ◽

Duplex Ultrasound ◽

Neurological Deficits ◽

Symptomatic Carotid ◽

Carotid Body Tumors ◽

Carotid Artery Endarterectomy ◽

Artery Disease ◽

Dissection Technique

Symptomatic carotid artery atherosclerotic disease is an indication for carotid artery endarterectomy. The coexistence of carotid body tumors (CBTs) with symptomatic carotid disease is rarely encountered and adds significant challenges to vascular surgeons, with a reported overall mortality for patients who undergo endarterectomy and tumor excision of 8.8%, as opposed to the 2% for those who had CBT excision only. We describe the case of a 79-year-old female who experienced an acute cerebrovascular accident in the left hemisphere; duplex ultrasound revealed high-grade carotid stenosis in the left side and the presence of a Shamblin I CBT. The risks and benefits of the planned operation were reviewed, and the decision was made to proceed with early carotid endarterectomy and concomitant surgical resection of the tumor using the retrocarotid dissection technique. The patient recovered well, and at 11 months from the combined procedure, her neurological deficits improved significantly.

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Carotid Endarterectomy for Symptomatic Carotid Artery Disease Demonstrated by Duplex Ultrasound With Minimal Arteriographic Findings

Annals of Vascular Surgery ◽

10.1007/bf02286785 ◽

1996 ◽

Vol 10 (4) ◽

pp. 385-389 ◽

Cited By ~ 6

Author(s):

Ali F. AbuRahma ◽

John F. White ◽

James P. Boland

Keyword(s):

Carotid Artery ◽

Carotid Endarterectomy ◽

Carotid Artery Disease ◽

Duplex Ultrasound ◽

Symptomatic Carotid ◽

Artery Disease

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Abstract 4: Angiographic Predictors of Stroke after Carotid Artery Stenting - A Qualitative and Quantitative Analysis of 1070 Patients in the Carotid Revascularization Endarterectomy versus Stenting Trial

Stroke ◽

10.1161/str.43.suppl_1.a4 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Gary S Roubin ◽

Jeffrey J Popma ◽

Alexandra Almonacid ◽

William F Morrish ◽

Barry T Katzen ◽

...

Keyword(s):

Carotid Artery ◽

Carotid Artery Disease ◽

Central Committee ◽

Lesion Length ◽

Quantitative Methodology ◽

Carotid Revascularization ◽

Qualitative And Quantitative ◽

Arterial Lumen ◽

Mouth Ulcer ◽

Periprocedural Stroke

Background Carotid artery stent (CAS) placement may be used as an alternative to carotid endarterectomy in selected patients with symptomatic and asymptomatic carotid artery disease. Perhaps because stroke is an uncommon event after CAS, the angiographic predictors of stroke have been incompletely described. Methods A total of 1070 catheter-based angiograms were centrally reviewed in patients undergoing CAS enrolled in the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST). Of these patients, 43 (4%) experienced periprocedural stroke. Angiograms were reviewed using qualitative and quantitative methodology before and after CAS. Reviews were done blinded to patient outcomes and strokes were adjudicated by a central committee blinded to results of angiography. The view showing the greatest carotid stenosis severity was selected. Extreme tortuosity was defined as 2 severe bends >90 degrees (maximum angulation/20 mm segment) beyond the target lesion, sequential lesions as lesions separated by ≥10 mm, and narrow mouth ulcer as a discrete area of contrast extension beyond the normal arterial lumen with a narrow inlet into the ulceration. Results The internal carotid artery reference diameter was 4.2 ± 0.8 mm, the minimal lumen diameter was 1.1 ± 0.6 mm, and the baseline % diameter stenosis was 74.1 ± 11.6%. There were no differences in vessel size or severity of the stenosis in patients with and without stroke. Morphologic predictors significantly related to the risk of subsequent stroke are listed in the Table . Calcification, lesion eccentricity, baseline flow, and distance from the bifurcation were not predictive of periprocedural stroke (p > 0.05). Conclusion In CREST, four angiographic variables were found to increase risk for stroke during and within 30 days after CAS: severe distal tortuosity, sequential lesions, lesion length > 20 mm, and narrow mouth ulcer. Angiographic characteristics beyond percent stenosis may help in patient selection in terms of best revascularization option.

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Multisite artery disease

ESC CardioMed ◽

10.1093/med/9780198784906.003.0783 ◽

2018 ◽

pp. 2733-2739

Author(s):

Marco De Carlo

Keyword(s):

Carotid Artery ◽

Patient Management ◽

Carotid Artery Disease ◽

Systematic Screening ◽

Carotid Revascularization ◽

Therapy Strategy ◽

Carotid Stenoses ◽

Artery Disease ◽

One Year ◽

Asymptomatic Disease

Multisite artery disease (MSAD) is common in patients with atherosclerotic involvement in one vascular bed, ranging from 10-15% in patients with CAD to 60-70% in patients with severe carotid stenosis or LEAD. MSAD is invariably associated with worse clinical outcomes; however, screening for asymptomatic disease in additional vascular sites has not been proven to improve prognosis. In patients with any presentation of PADs, clinical assessment of symptoms and physical signs of other localizations and/or CAD is necessary, and in case of clinical suspicion, further tests may be planned. Systematic screening for asymptomatic MSAD is not indicated for any presentation of PADs as it would not consistently lead to a modification of management strategy. It may be interesting in some cases for risk stratification (e.g. antiplatelet therapy strategy beyond one year in patients who benefited from coronary stenting for ACS). In some situations the identification of asymptomatic lesions may affect patient management. This is the case for patients undergoing CABG, where ABI measurement may be considered especially when saphenous vein harvesting is planned, and carotid screening should be considered in a subset of patients at high risk of carotid artery disease. In patients scheduled for CABG with severe carotid stenoses, prophylactic carotid revascularization should be considered in recently symptomatic cases and may be considered in asymptomatic cases, after multidisciplinary discussion. In patients planned for carotid artery revascularization for asymptomatic stenosis, a preoperative coronary angiography for detection (and revascularization) of CAD may be considered.

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Preventing stroke in symptomatic carotid artery disease during the COVID-19 pandemic

Journal of Vascular Surgery ◽

10.1016/j.jvs.2020.04.476 ◽

2020 ◽

Vol 72 (2) ◽

pp. 755-756

Author(s):

Joyce Hellegering ◽

Maarten J. van der Laan ◽

Erik-Jan de Heide ◽

Maarten Uyttenboogaart ◽

Clark J. Zeebregts ◽

...

Keyword(s):

Carotid Artery ◽

Carotid Artery Disease ◽

Symptomatic Carotid ◽

Artery Disease

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Exploration of a zero-tolerance regime on cerebral embolism in symptomatic carotid artery disease

Perspectives in Medicine ◽

10.1016/j.permed.2012.02.064 ◽

2012 ◽

Vol 1 (1-12) ◽

pp. 218-223 ◽

Cited By ~ 1

Author(s):

Ruud W.M. Keunen ◽

Agnes van Sonderen ◽

Maayke Hunfeld ◽

Michael Remmers ◽

D.L. Tavy ◽

...

Keyword(s):

Carotid Artery ◽

Carotid Artery Disease ◽

Zero Tolerance ◽

Cerebral Embolism ◽

Symptomatic Carotid ◽

Artery Disease

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Circulating Microparticles in Patients with Symptomatic Carotid Disease Are Related to Embolic Plaque Activity and Recent Cerebral Ischaemia

Cerebrovascular Diseases Extra ◽

10.1159/000495942 ◽

2019 ◽

Vol 9 (1) ◽

pp. 9-18 ◽

Cited By ~ 2

Author(s):

Neghal Kandiyil ◽

Shane T. MacSweeney ◽

Stan Heptinstall ◽

Jane May ◽

Susan C. Fox ◽

...

Keyword(s):

Carotid Artery ◽

Cerebral Ischaemia ◽

Carotid Artery Disease ◽

Transcranial Doppler Ultrasound ◽

Risk Markers ◽

Stroke Patients ◽

Symptomatic Carotid ◽

Circulating Microparticles ◽

Artery Disease ◽

Embolic Signals

Background and Purpose: In order to assess the association of microparticles derived from activated platelets (PMP) or endothelial cells (EMP) with risk markers for recurrent embolic events in patients with symptomatic carotid artery disease, we studied the associations between PMP/EMP and three risk markers: plaque haemorrhage (PH), micro-embolic signals and cerebral diffusion abnormalities. Methods: Patients with recently symptomatic high-grade carotid artery stenosis (60–99%, 42 patients, 31 men; mean age 75 ± 8 years) and 30 healthy volunteers (HV, 11 men; mean age 56 ± 12 years) were prospectively recruited. Patients were characterised by carotid magnetic resonance imaging (presence of PH [MRI PH]), brain diffusion MRI (cerebral ischaemia [DWI+]) and transcranial Doppler ultrasound (micro-embolic signals [MES+]). PMP and EMP were classified by flow cytometry and expressed as log-transformed counts per microlitre. Results: MES+ patients (n = 18) had elevated PMP (MES+ 9.61 ± 0.57) compared to HV (8.80 ± 0.73; p < 0.0001) and to MES– patients (8.55 ± 0.85; p < 0.0001). Stroke patients had elevated PMP (9.49 ± 0.64) and EMP (6.13 ± 1.0) compared to non-stroke patients (PMP 8.81 ± 0.73, p = 0.026, EMP 5.52 ± 0.65, p = 0.011) and HV (PMP 8.80 ± 0.73, p = 0.007, and EMP 5.44 ± 0.47, p = 0.006). DWI+ patients (n = 16) showed elevated PMP (DWI+ 9.53 ± 0.64; vs. HV, p = 0.002) and EMP (DWI+ 5.91 ± 0.99 vs. HV 5.44 ± 0.47; p = 0.037). Only PMP but not EMP were higher in DWI+ versus DWI– patients (8.67 ± 0.90; p = 0.002). No association was found between PMP and EMP with MRI PH. Conclusions: PMP and EMP were associated with stroke and recent cerebrovascular events (DWI+) but only PMP were also associated with ongoing (MES+) thrombo-embolic activity suggesting a differential biomarker potential for EMP to index cerebral ischaemia while PMP may predict on-going thrombo-embolic activity.

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