Aggressive Medical Therapy Alone Is Not Adequate in Certain Patients With Severe Symptomatic Carotid Stenosis

Background and Purpose: No systematic review of the literature has dedicated itself to looking at the management of symptomatic carotid stenosis in women. In this scoping review, we aimed to identify all randomized controlled trials (RCTs) that reported sex-specific outcomes for patients who underwent carotid revascularization, and determine whether sufficient information is reported within these studies to assess women’s short and long-term outcomes. Methods: We systematically searched Medline, Embase, Pubmed, and Cochrane libraries for RCTs published between 1991 and 2020 that included women and compared either endarterectomy with stenting, or any revascularization (endarterectomy or stenting) with medical therapy in patients with symptomatic high grade (greater than 50%) carotid stenosis. Results: From 1,537 references examined, 27 eligible studies were identified. Sex-specific outcomes were reported in 13 studies. Baseline patient characteristics of enrolled women were reported in 2 of those 13 studies. Common outcomes reported included stroke and death, however there was significant heterogeneity in the reporting of both periprocedural and long-term outcomes. Sex-specific differences relating to the degree of stenosis and time from index event to treatment were limited to studies comparing endarterectomy to medical therapy. Adverse events were not reported by sex. Conclusions: Half of the previously published RCTs and systematic reviews report sex-specific outcomes. Detailed analysis on the benefits of carotid artery intervention for women with symptomatic stenosis is limited . Further analysis with individual patient data and a network meta-analysis is the necessary next step to better assess the treatment effects of carotid management in women.

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Identifying sex-specific differences in the carotid revascularisation literature: findings from a scoping review

Stroke and Vascular Neurology ◽

10.1136/svn-2020-000744 ◽

2021 ◽

pp. svn-2020-000744

Author(s):

Vignan Yogendrakumar ◽

Michel Shamy ◽

Brian Dewar ◽

Dean A Fergusson ◽

Dar Dowlatshahi ◽

...

Keyword(s):

Carotid Stenosis ◽

Medical Therapy ◽

Scoping Review ◽

Sufficient Information ◽

Significant Heterogeneity ◽

Long Term Outcomes ◽

Symptomatic Carotid ◽

Female Patients ◽

Symptomatic Carotid Stenosis

ObjectiveNo systematic review of the literature has dedicated itself to looking at the management of symptomatic carotid stenosis in female patients. In this scoping review, we aimed to identify all randomised controlled trials (RCTs) that reported sex-specific outcomes for patients who underwent carotid revascularisation, and determine whether sufficient information is reported within these studies to assess short-term and long-term outcomes in female patients.Design, setting and participantsWe systematically searched Medline, Embase, Pubmed and Cochrane libraries for RCTs published between 1991 and 2020 that included female patients and compared either endarterectomy with stenting, or any revascularisation (endarterectomy or stenting) with medical therapy in patients with symptomatic high-grade (>50%) carotid stenosis.ResultsFrom 1537 references examined, 27 eligible studies were identified. Sex-specific outcomes were reported in 13 studies. Baseline patient characteristics of enrolled female patients were reported in 2 of those 13 studies. Common outcomes reported included stroke and death, however, there was significant heterogeneity in the reporting of both periprocedural and long-term outcomes. Sex-specific differences relating to the degree of stenosis and time from index event to treatment are largely limited to studies comparing endarterectomy to medical therapy. Adverse events were not reported by sex.ConclusionsOnly half of the previously published RCTs and systematic reviews report sex-specific outcomes. Detailed analyses on the results of carotid artery intervention for female patients with symptomatic stenosis are limited.

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Abstract 53: Development of Standardized Approach in Symptomatic Carotid Stenosis for Early Intervention

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/circoutcomes.5.suppl_1.a53 ◽

2012 ◽

Vol 5 (suppl_1) ◽

Author(s):

Paola De Rango ◽

Massimo Lenti ◽

Valeria Caso ◽

Enrico Cieri ◽

Gioele Simonte ◽

...

Keyword(s):

Carotid Stenosis ◽

Medical Therapy ◽

Duplex Ultrasound ◽

Recurrence Risk ◽

Neurological Status ◽

Plaque Morphology ◽

Vascular Surgeon ◽

Symptomatic Carotid ◽

Cerebrovascular Events ◽

Symptomatic Carotid Stenosis

Background: Despite current guidelines recommend performing carotid endarterectomy (CEA) within the first 7-14 days from symptoms onset, this is not the routine approach for symptomatic carotid stenosis in most countries because of logistic difficulties and concerns regarding perioperative risk of “urgent CEA”. The aim of this study was to implement a multi-service in-hospital protocol to standardize the approach and reduce recurrence risk in acute symptomatic carotid stenosis without radical logistic reorganizations. Methods: All patients referred to the Emergency Room (ER) for acute cerebrovascular events will be seen within 24hours by the neurovascular specialist on call who rapidly triages patients (ABCD2 score), starts optimum medical therapy and performs carotid duplex ultrasound in the ER where immediate cerebral imaging will be also done by the neuroradiologist on call. Patients with 50-99% stenosis are discussed with the vascular surgeon on call and treatment decided (CEA vs stenting vs medical therapy) according to patients’ comorbidities, neurological status and carotid plaque morphology. Decision for intervention implies immediate transferal to the Vascular Surgery Unit where treatment is guaranteed within 2-48 hours in a hybrid operating room. The neurovascular specialist follows all postoperative courses (eventual transferal to Stroke Unit can be decided). Results: Before the application of the standardized protocol, over 2002 consecutive carotid interventions, 684 were performed for symptomatic stenosis with perioperative stroke/death risk of 3.5%, similar in Stenting and CEA. The stroke risk at 5 years after the procedure was 8.7% after CEA vs. 4.9% after stenting (p =0.7). However, there was extreme variability in symptoms-to-treatment delay. Conclusion: Multidisciplinary team collaboration among traditional 24h availability local services would standardize the approach to carotid stenosis in symptomatic patients without substantially changes in hospital services and relevant logistic reorganization. The efficacy of stenting in early treatment will be verified. Increased prevalence of symptomatic interventions and improved stroke prevention rates are expected with the new protocol.

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Urgent Best Medical Therapy May Obviate the Need for Urgent Surgery in Patients With Symptomatic Carotid Stenosis

Stroke ◽

10.1161/strokeaha.111.000798 ◽

2013 ◽

Vol 44 (8) ◽

pp. 2220-2225 ◽

Cited By ~ 33

Author(s):

S. Shahidi ◽

A. Owen-Falkenberg ◽

U. Hjerpsted ◽

A. Rai ◽

K. Ellemann

Keyword(s):

Carotid Stenosis ◽

Medical Therapy ◽

Symptomatic Carotid ◽

Urgent Surgery ◽

Symptomatic Carotid Stenosis ◽

Best Medical Therapy

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Abstract T MP26: Progression Of Asymptomatic Carotid Stenosis: Incidence Of Symptoms And Predictive Factors

Stroke ◽

10.1161/str.46.suppl_1.tmp26 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Tarun Singh ◽

Christopher L Kramer ◽

Giuseppe Lanzino ◽

Alejandro A Rabinstein

Keyword(s):

Carotid Stenosis ◽

Medical Therapy ◽

Previous History ◽

Multivariate Logistic Regression Analysis ◽

Asymptomatic Carotid ◽

Symptomatic Carotid ◽

Symptomatic Carotid Stenosis ◽

Bilateral Carotid

Background: Given the uncertainty regarding clinical applicability of early treatment trials and lack of data on long-term disease progression, we evaluated the progression of stenosis and development of symptoms on patients with asymptomatic carotid artery stenosis (ACAS) treated with contemporary medical therapy over a prolonged follow up. Methods: Retrospective review of bilateral carotid arteries from consecutive patients diagnosed with moderate or severe ACAS, at our institution between 2000 and 2001. Patient vascular risk factors and treatments, cerebrovascular imaging, ipsilateral symptoms, and revascularization were recorded. Progression of stenosis was defined by change category of stenosis. Factors associated with symptomatic carotid disease were sought using univariate and multivariate logistic regression analysis. Results: We identified 214 patients (58.8% men; median age 70 years) and collected data on 349 vessels. Severe stenosis (>70%) upon diagnosis was present in 92(26.4%) vessels. All patients were on antithrombotics, 97% on antihypertensives, and 95% on statins. Median length of follow up was 13 years (range 5-14) and the mean number of time points with follow-up imaging was 8.1±3.9. Progression of stenosis was observed in 237(67.9%) vessels. 72(20.6%) patients developed symptomatic carotid stenosis (TIA in 14.4%, non-disabling stroke in 4%, and disabling stroke in 2.2%). Median time to appearance of first symptom was 6 years (range 1-13). Revascularization procedures were performed in 118(33.8%) vessels, including 73(61.9%) vessels which had become symptomatic. On multivariate analysis, baseline stenosis (OR 1.65, 95%CI 1.12-2.44), intracranial stenosis > 50% (OR 2.87, 95%CI 1.46-5.62), plaque ulceration (OR 3.41, 95%CI 1.34-8.69), silent infarction (OR 4.25, 95%CI 2.30-7.83), and previous history of TIA/stroke (OR 2.73, 95%CI 1.14-6.54) were associated with development of TIA/stroke ipsilateral to the carotid stenosis. Conclusions: There is a substantial rate of progression of stenosis in patients with asymptomatic carotid atherosclerosis over time despite adequate medical therapy. Over long-term follow up, one in five patients with ACAS developed ipsilateral TIA/stroke.

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