scholarly journals Trends and controversies in carotid artery stenosis treatment

F1000Research ◽  
2020 ◽  
Vol 9 ◽  
pp. 940
Author(s):  
Rakhee Lalla ◽  
Prashant Raghavan ◽  
Seemant Chaturvedi
Keyword(s):  
Carotid Stenosis ◽  
Imaging Techniques ◽  
Current Treatment ◽  
Resonance Imaging ◽  
Asymptomatic Carotid Stenosis ◽  
Asymptomatic Carotid ◽  
Carotid Revascularization ◽  
Symptomatic Stenosis ◽  
Key Questions

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.

Abstract 17291: Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis: CREST-2 update

Circulation ◽  
2015 ◽  
Vol 132 (suppl_3) ◽  
Author(s):  
James Meschia ◽  
Brajesh K Lal ◽  
George Howard ◽  
Gary Roubin ◽  
Robert D Brown ◽  
...  
Keyword(s):  
Carotid Stenosis ◽  
Medical Therapy ◽  
Primary Outcome ◽  
Randomized Clinical Trials ◽  
Carotid Stenting ◽  
Current Treatment ◽  
Asymptomatic Carotid Stenosis ◽  
Asymptomatic Carotid ◽  
Carotid Revascularization ◽  
Asymptomatic Patients

Purpose: The safety of revascularization for asymptomatic carotid stenosis, and the efficacy of medical therapy for stroke prevention have improved. Therefore, results of prior randomized trials may not apply to current treatment decisions. The NINDS-funded CREST-2 will compare carotid endarterectomy and intensive medical therapy (IMT) versus IMT alone (n=1240), and carotid stenting and IMT versus IMT alone (n=1240) in asymptomatic patients with≥70% stenosis. Materials & Methods: CREST-2 consists of two parallel randomized clinical trials to be conducted at a target of ≈120 centers, including within NINDS StrokeNet. The composite primary outcome is stroke or death during the peri-procedural period or ipsilateral ischemic stroke thereafter up to 4 years. Blinded assessment of cognition will be done periodically. Centrally directed IMT includes tight control of blood pressure (systolic target <140 mm Hg) and cholesterol (LDL target <70 mg/dl) as well as lifestyle coaching. Results: As of June 12, 2015, 94 centers have been approved by the Site Selection Committee. Credentialing is ongoing, with 198 approved surgeons and 64 approved interventionists; 124 additional conditionally approved interventionists will be able to submit additional cases for review under the CREST-2 Registry. The Centers for Medicare and Medicaid will offer CAS reimbursement for Registry enrollees. As of June 12, 2015, there are 39 actively enrolling centers, and 37 patients have been randomized. Conclusion: CREST-2 is designed to identify the best approach for asymptomatic carotid stenosis. The first patient was randomized in December, 2014. An update will be provided regarding the numbers of patients randomized, centers certified, as well as surgeons and interventionists fully approved. Registration: ClinicalTrials.gov Identifier: NCT02089217

Abstract 2956: Carotid Revascularization in Elderly Asymptomatic Patients: Are the Results Optimal?

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Rahul H Damani ◽  
Mahmoud Rayes ◽  
Pratik Bhattacharya ◽  
Seemant Chaturvedi
Keyword(s):  
Elderly Patients ◽  
Carotid Stenosis ◽  
Medical Therapy ◽  
Beta Blockers ◽  
Asymptomatic Carotid Stenosis ◽  
Asymptomatic Carotid ◽  
Carotid Revascularization ◽  
Asymptomatic Patients ◽  
Operative Complications ◽  
Best Medical Therapy

Objectives: Assess the hypothesis that patients with asymptomatic carotid stenosis older than 75 years are not on “best medical therapy” and their operative complication exceeds the AHA/ASA 3% threshold. Background: According to the Asymptomatic Carotid Atherosclerosis Study (ACAS), the Asymptomatic Carotid Surgery Trial (ACST) and recent AHA/ASA guidelines; benefits of carotid revascularization in asymptomatic patient >75 years would be offset if the operative complications rate exceed 3% and it would be more prudent to manage such patients on “best medical therapy”. How often these guidelines are being followed remains unclear. Methods: A retrospective chart review (2009-2011) at three urban, one suburban hospital within 30 miles was performed. Information of carotid revascularization (CEA & CAS) in asymptomatic elderly patients, in-hospital outcomes of stroke/death and/or MI and pre-procedural medications were evaluated. Statistical analysis with chi square testing was used. Results: A total of 114 patients met our inclusion criteria. Their features are described below.At four hospitals, the proportion of carotid revascularization done was 62% (114/185). More then quarter and one-third of patients undergoing carotid revascularization were not on statin and beta-blockers, respectively. Further, the rate of in hospital stroke was 4.4%. Conclusions: The majority of elderly patients with asymptomatic carotid stenosis patients are still undergoing carotid revascularization with operative complications that exceeded the AHA/ASA 3% threshold. More then quarter of patients in this subgroup are not on “best medical therapy”. These results reinforce the need for a new clinical trial comparing aggressive medical therapy alone vs. aggressive medical therapy and revascularization.

scholarly journals Carotid revascularization and medical management for asymptomatic carotid stenosis – Hemodynamics (CREST-H): Study design and rationale

2018 ◽  
Vol 13 (9) ◽  
pp. 985-991 ◽  
Author(s):  
Randolph S Marshall ◽  
Ronald M Lazar ◽  
David S Liebeskind ◽  
E Sander Connolly ◽  
George Howard ◽  
...  
Keyword(s):  
Cognitive Impairment ◽  
White Matter ◽  
Carotid Stenosis ◽  
Medical Management ◽  
Cerebral Microbleeds ◽  
White Matter Hyperintensity ◽  
Asymptomatic Carotid Stenosis ◽  
Asymptomatic Carotid ◽  
Carotid Revascularization ◽  
One Year

Rationale For patients with asymptomatic high-grade carotid stenosis, clinical investigations have focused on preventing cerebral infarction, yet stenosis that reduces cerebral blood flow may independently impair cognition. Whether revascularization of a hemodynamically significant carotid stenosis can alter the course of cognitive decline has never been investigated in the context of a randomized clinical trial. Hypothesis Among patients randomized in the Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis (CREST-2) trials, the magnitude of treatment differences (revascularization versus medical management alone) with regard to cognition will differ between those with flow impairment compared to those without flow impairment. Sample size We will enroll approximately 500 patients from CREST-2, of which we anticipate 100 will have hemodynamic impairment. We estimate 93% power to detect a clinically meaningful treatment difference of 0.5 SD. Methods and design We will use perfusion-weighted magnetic resonance imaging to stratify by hemodynamic status. Linear regression will compare treatment differences, controlling for baseline cognitive status, age, depression, prior cerebral infarcts, silent infarction, white matter hyperintensity volume, and cerebral microbleeds. Study outcomes The primary outcome is change in cognition at one year. Secondary outcomes include silent infarction, change in white matter hyperintensity volume, number of cerebral microbleeds, and cortical thickness over one year. Discussion If cognitive impairment can be shown to be reversible by revascularization, then we can redefine “symptomatic carotid stenosis” to include cognitive impairment and identify a new population of patients likely to benefit from revascularization. Trial Registration US National Institutes of Health (NIH) clinicaltrials.gov NCT03121209

scholarly journals The CREST-2 experience with the evolving challenges of COVID-19

Neurology ◽  
2020 ◽  
Vol 95 (1) ◽  
pp. 29-36 ◽  
Author(s):  
James F. Meschia ◽  
Kevin M. Barrett ◽  
Robert D. Brown ◽  
Tanya N. Turan ◽  
Virginia J. Howard ◽  
...  
Keyword(s):  
Carotid Stenosis ◽  
Medical Management ◽  
Neurological Disorders ◽  
Stroke Prevention ◽  
Prevention Trial ◽  
Asymptomatic Carotid Stenosis ◽  
Asymptomatic Carotid ◽  
Ethical Obligation ◽  
Carotid Revascularization

The coronavirus disease 2019 pandemic has disrupted the lives of whole communities and nations. The multinational multicenter National Institute of Neurological Disorders and Stroke Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial stroke prevention trial rapidly experienced the effects of the pandemic and had to temporarily suspend new enrollments and shift patient follow-up activities from in-person clinic visits to telephone contacts. There is an ethical obligation to the patients to protect their health while taking every feasible step to ensure that the goals of the trial are successfully met. Here, we describe the effects of the pandemic on the trial and steps that are being taken to mitigate the effects of the pandemic so that trial objectives can be met.

scholarly journals Identification, risk stratification and prognostication of stroke by detection of intra-carotid plaque hemorrhage

2021 ◽  
Vol 28 (Supplement_1) ◽  
Author(s):  
H Maqsood ◽  
S Younus ◽  
M Saim ◽  
S Qazi ◽  
A Basit ◽  
...  
Keyword(s):  
Magnetic Resonance Imaging ◽  
Magnetic Resonance ◽  
Carotid Artery ◽  
Carotid Stenosis ◽  
Resonance Imaging ◽  
Asymptomatic Carotid Stenosis ◽  
Asymptomatic Carotid ◽  
Symptomatic Carotid ◽  
Atherosclerotic Stenosis ◽  
Symptomatic Carotid Stenosis

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Atherosclerotic stenosis of the internal carotid artery is present in 1% to 2% of the adult population and is the cause of  10% to 15% of ischemic strokes. Intra-plaque hemorrhage (IPH) in carotid stenosis increases the risk of cerebrovascular events. Magnetic resonance imaging can be used to detect pathologies like IPH and necrosis in carotid stenosis. Purpose : This study sought to compare the risk of stroke between patients with carotid artery disease with and without the presence of intraplaque hemorrhage (IPH) on magnetic resonance imaging. Methods : In this meta-analysis we gathered the data from 10 original cohort studies including 631 patients with symptomatic carotid stenosis and 157 patients with asymptomatic carotid stenosis. Primary outcome was the hazards of ipsilateral ischemic stroke which were compared between patients with and without IPH. Results : IPH was present in 57.1% of patients with symptomatic carotid stenosis and 24.7% of patients with asymptomatic carotid stenosis. During 1,334 observed person-years, 74 ipsilateral strokes occurred. Presence of IPH at baseline increased the risk of ipsilateral stroke both in symptomatic (hazard ratio [HR]: 11.7; 95% confidence interval [CI]: 4.7 to 22.8) and asymptomatic (HR: 6.8; 95% CI: 0.9 to 45.4) patients. Multivariate analysis identified IPH (HR: 11.7; 95% CI: 5.3 to 26.4) and severe degree of stenosis (HR: 3.8; 95% CI: 02 to 8.2) as independent predictors of ipsilateral stroke. Conclusion : Our study concludes that IPH is common in patients with carotid artery stenosis and is a stronger predictor of stroke. Magnetic resonance imaging is the modality that can help in identification of patients with carotid disease who would benefit from revascularization.

Carotid stenosis - When is revascularization appropriate?

VASA ◽  
2009 ◽  
Vol 38 (3) ◽  
pp. 203-211
Author(s):  
Koennecke
Keyword(s):  
Carotid Stenosis ◽  
Cardiovascular Events ◽  
Common Condition ◽  
Asymptomatic Carotid Stenosis ◽  
Asymptomatic Carotid ◽  
Atherosclerotic Lesions ◽  
Mri Features ◽  
Carotid Stenoses ◽  
Risk Patients ◽  
Symptomatic Stenosis

Approximately 15% of ischemic strokes are caused by extracranial carotid stenoses. Revascularization of a symptomatic stenosis is very efficacious in carefully selected patients. This review outlines criteria which help to identify those who will benefit most from carotid endarterectomy (CEA) for symptomatic stenosis. Asymptomatic carotid stenosis is a common condition in the general population over 50 years, but nonetheless associated with a low risk of ischemic stroke. Consequently, the therapeutic yield of CEA is much lower in asymptomatic stenosis and women seem not to benefit at all. In the future, specific morphological MRI features may help to identify stenoses prone to become symptomatic. In addition to their significance for stroke, it has been demonstrated that atherosclerotic lesions can be regarded as an indicator of cardiovascular morbidity which may help to identify high-risk patients for cardiovascular events.

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