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Carotid Disease Management: Surgery, Stenting, or Medication

  • Stroke (D Wang, Section Editor)
  • Published:
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Abstract

Internal carotid artery stenosis accounts for about 7–10 % of ischemic strokes. Conventional risk factors such as aging, hypertension, diabetes mellitus, and smoking increase the risk for carotid atherosclerosis. All patients with carotid stenosis should receive aggressive medical therapy. Carotid revascularization with either endarterectomy or stenting can benefit select patients with severe stenosis. New clinical trials will examine the contemporary role of carotid revascularization relative to optimal medical therapy.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Kernan WN, Ovbiagele B, Black HR, et al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke J Cereb Circ. 2014;45:2160–236.

    Article  Google Scholar 

  2. Chaturvedi S, Bhattacharya P. Large artery atherosclerosis: carotid stenosis, vertebral artery disease, and intracranial atherosclerosis. Continuum (Minneapolis, Minn). Cerebrovasc Dis. 2014;20:323–34.

    Google Scholar 

  3. Flaherty ML, Kissela B, Khoury JC, et al. Carotid artery stenosis as a cause of stroke. Neuroepidemiology. 2013;40:36–41.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Barnett HJ, Gunton RW, Eliasziw M, et al. Causes and severity of ischemic stroke in patients with internal carotid artery stenosis. JAMA. 2000;283:1429–36.

    Article  CAS  PubMed  Google Scholar 

  5. Mathiesen EB, Joakimsen O, Bonaa KH. Prevalence of and risk factors associated with carotid artery stenosis: the Tromso Study. Cerebrovasc Dis Basel Switzerland. 2001;12:44–51.

    Article  CAS  Google Scholar 

  6. Salem MK, Sayers RD, Bown MJ, et al. Patients with recurrent ischaemic events from carotid artery disease have a large lipid core and low GSM. Eur J Vasc Endovasc Surg. 2012;43:147–53.

    Article  CAS  PubMed  Google Scholar 

  7. Hosseini AA, Kandiyil N, Macsweeney ST, Altaf N, Auer DP. Carotid plaque hemorrhage on magnetic resonance imaging strongly predicts recurrent ischemia and stroke. Ann Neurol. 2013;73:774–84.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Eastcott HH, Pickering GW, Rob CG. Reconstruction of internal carotid artery in a patient with intermittent attacks of hemiplegia. Lancet. 1954;267:994–6.

    Article  CAS  PubMed  Google Scholar 

  9. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. New England J Med. 1991;325:445–53.

  10. European MRC. Carotid surgery trial: interim results for symptomatic patients with severe (70-99%) or with mild (0-29%) carotid stenosis. European Carotid Surgery Trialists’ Collaborative Group. Lancet. 1991;337:1235–43.

    Article  Google Scholar 

  11. Mayberg MR, Wilson SE, Yatsu F, et al. Carotid endarterectomy and prevention of cerebral ischemia in symptomatic carotid stenosis. Veterans Affairs Cooperative Studies Program 309 Trialist Group. JAMA. 1991;266:3289–94.

    Article  CAS  PubMed  Google Scholar 

  12. Rothwell PM, Eliasziw M, Gutnikov SA, et al. Analysis of pooled data from the randomised controlled trials of endarterectomy for symptomatic carotid stenosis. Lancet. 2003;361:107–16.

    Article  CAS  PubMed  Google Scholar 

  13. Barnett HJ, Taylor DW, Eliasziw M, et al. Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med. 1998;339:1415–25.

    Article  CAS  PubMed  Google Scholar 

  14. Tu JV, Wang H, Bowyer B, Green L, Fang J, Kucey D. Risk factors for death or stroke after carotid endarterectomy: observations from the Ontario Carotid Endarterectomy Registry. Stroke J Cerebr Circ. 2003;34:2568–73.

    Article  Google Scholar 

  15. Metzger DC. Embolic protection in carotid artery stenting: new options. Tech Vasc Interv Radiol. 2011;14:86–94.

    Article  PubMed  Google Scholar 

  16. Stoner MC, Abbott WM, Wong DR et al. Defining the high-risk patient for carotid endarterectomy: an analysis of the prospective National Surgical Quality Improvement Program database. J Vasc Surg;43:285–96.e2

  17. Yadav JS, Wholey MH, Kuntz RE, et al. Protected carotid-artery stenting versus endarterectomy in high-risk patients. N Engl J Med. 2004;351:1493–501.

    Article  CAS  PubMed  Google Scholar 

  18. Ringleb PA, Allenberg J, Bruckmann H, et al. 30 day results from the SPACE trial of stent-protected angioplasty versus carotid endarterectomy in symptomatic patients: a randomised non-inferiority trial. Lancet. 2006;368:1239–47.

    Article  CAS  PubMed  Google Scholar 

  19. Mas JL, Chatellier G, Beyssen B, et al. Endarterectomy versus stenting in patients with symptomatic severe carotid stenosis. N Engl J Med. 2006;355:1660–71.

    Article  CAS  PubMed  Google Scholar 

  20. Brott TG, Hobson 2nd RW, Howard G, et al. Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med. 2010;363:11–23.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  21. Ederle J, Dobson J, Featherstone RL, et al. Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): an interim analysis of a randomised controlled trial. Lancet. 2010;375:985–97.

    Article  PubMed  Google Scholar 

  22. Bonati LH, Dobson J, Algra A, et al. Short-term outcome after stenting versus endarterectomy for symptomatic carotid stenosis: a preplanned meta-analysis of individual patient data. Lancet. 2010;376:1062–73.

    Article  PubMed  Google Scholar 

  23. Bonati LH, Lyrer P, Ederle J, Featherstone R, Brown MM. Percutaneous transluminal balloon angioplasty and stenting for carotid artery stenosis. The Cochrane Database of Systematic Reviews 2012;9:Cd000515.

  24. Clinical alert: benefit of carotid endarterectomy for patients with high-grade stenosis of the internal carotid artery. National Institute of Neurological Disorders and Stroke and Trauma Division. North American Symptomatic Carotid Endarterectomy Trial (NASCET) investigators. Stroke J Cereb Circ. 1991;22:816–7.

  25. Endarterectomy for asymptomatic carotid artery stenosis. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. JAMA. 1995;273:1421–8

  26. 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;363:1491–502.

    Article  CAS  PubMed  Google Scholar 

  27. Chambers BR, Donnan GA. Carotid endarterectomy for asymptomatic carotid stenosis. The Cochrane Database of Systematic Reviews 2005:Cd001923.

  28. Silver FL, Mackey A, Clark WM, et al. Safety of stenting and endarterectomy by symptomatic status in the carotid revascularization endarterectomy versus stenting trial (CREST). Stroke J Cereb Circ. 2011;42:675–80.

    Article  Google Scholar 

  29. Inzitari D, Eliasziw M, Gates P, et al. The causes and risk of stroke in patients with asymptomatic internal-carotid-artery stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med. 2000;342:1693–700.

    Article  CAS  PubMed  Google Scholar 

  30. Abbott AL. Medical (nonsurgical) intervention alone is now best for prevention of stroke associated with asymptomatic severe carotid stenosis: results of a systematic review and analysis. Stroke J Cereb Circ. 2009;40:e573–83.

    Article  Google Scholar 

  31. Wylie EJ, Hein MF, Adams JE. Intracranial hemorrhage following surgical revascularization for treatment of acute strokes. J Neurosurg. 1964;21:212–5.

    Article  CAS  PubMed  Google Scholar 

  32. Bruetman ME, Fields WS, Crawford ES, Debakey ME. Cerebral hemorrhage as a complication of surgery in carotid artery occlusion. Trans Am Neurol Assoc. 1963;88:52–5.

    CAS  PubMed  Google Scholar 

  33. Piepgras DG, Morgan MK, Sundt Jr TM, Yanagihara T, Mussman LM. Intracerebral hemorrhage after carotid endarterectomy. J Neurosurg. 1988;68:532–6.

    Article  CAS  PubMed  Google Scholar 

  34. Ferguson GG, Eliasziw M, Barr HW, et al. The North American Symptomatic Carotid Endarterectomy Trial: surgical results in 1415 patients. Stroke J Cereb Circ. 1999;30:1751–8.

    Article  CAS  Google Scholar 

  35. Johnston SC, Gress DR, Browner WS, Sidney S. Short-term prognosis after emergency department diagnosis of TIA. JAMA. 2000;284:2901–6.

    Article  CAS  PubMed  Google Scholar 

  36. Lovett JK, Coull AJ, Rothwell PM. Early risk of recurrence by subtype of ischemic stroke in population-based incidence studies. Neurology. 2004;62:569–73.

    Article  CAS  PubMed  Google Scholar 

  37. Rothwell PM, Eliasziw M, Gutnikov SA, Warlow CP, Barnett HJ. Endarterectomy for symptomatic carotid stenosis in relation to clinical subgroups and timing of surgery. Lancet. 2004;363:915–24.

    Article  CAS  PubMed  Google Scholar 

  38. Bond R, Rerkasem K, Cuffe R, Rothwell PM. A systematic review of the associations between age and sex and the operative risks of carotid endarterectomy. Cerebrovasc Dis Basel Switzerland. 2005;20:69–77.

    Article  CAS  Google Scholar 

  39. Rothwell PM, Slattery J, Warlow CP. Clinical and angiographic predictors of stroke and death from carotid endarterectomy: systematic review. BMJ Clin Res Ed. 1997;315:1571–7.

    Article  CAS  Google Scholar 

  40. Alamowitch S, Eliasziw M, Barnett HJ. The risk and benefit of endarterectomy in women with symptomatic internal carotid artery disease. Stroke J Cereb Circ. 2005;36:27–31.

    Article  Google Scholar 

  41. Howard VJ, Lutsep HL, Mackey A, et al. Influence of sex on outcomes of stenting versus endarterectomy: a subgroup analysis of the carotid revascularization endarterectomy versus stenting trial (CREST). Lancet Neurol. 2011;10:530–7.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Halliday A, Harrison M, Hayter E, et al. 10-year stroke prevention after successful carotid endarterectomy for asymptomatic stenosis (ACST-1): a multicentre randomised trial. Lancet. 2010;376:1074–84.

    Article  PubMed  PubMed Central  Google Scholar 

  43. Voeks JH, Howard G, Roubin GS, et al. Age and outcomes after carotid stenting and endarterectomy: the carotid revascularization endarterectomy versus stenting trial. Stroke J Cereb Circ. 2011;42:3484–90. Important paper showing the impact of age on carotid surgery and stenting complication rates.

    Article  Google Scholar 

  44. Bond R, Rerkasem K, Rothwell PM. Systematic review of the risks of carotid endarterectomy in relation to the clinical indication for and timing of surgery. Stroke J Cereb Circ. 2003;34:2290–301.

    Article  CAS  Google Scholar 

  45. Lal BK, Beach KW, Roubin GS, et al. Restenosis after carotid artery stenting and endarterectomy: a secondary analysis of CREST, a randomised controlled trial. Lancet Neurol. 2012;11:755–63.

    Article  PubMed  PubMed Central  Google Scholar 

  46. Altinbas A, Algra A, Bonati LH, et al. Periprocedural hemodynamic depression is associated with a higher number of new ischemic brain lesions after stenting in the International Carotid Stenting Study-MRI Substudy. Stroke J Cereb Circ. 2014;45:146–51.

    Article  Google Scholar 

  47. Ogasawara K, Yukawa H, Kobayashi M, et al. Prediction and monitoring of cerebral hyperperfusion after carotid endarterectomy by using single-photon emission computerized tomography scanning. J Neurosurg. 2003;99:504–10.

    Article  PubMed  Google Scholar 

  48. Abou-Chebl A, Yadav JS, Reginelli JP, Bajzer C, Bhatt D, Krieger DW. Intracranial hemorrhage and hyperperfusion syndrome following carotid artery stenting: risk factors, prevention, and treatment. J Am Coll Cardiol. 2004;43:1596–601.

    Article  PubMed  Google Scholar 

  49. Macdonald S, Lee R, Williams R, Stansby G. Towards safer carotid artery stenting: a scoring system for anatomic suitability. Stroke J Cereb Circ. 2009;40:1698–703.

    Article  Google Scholar 

  50. Roubin GS, Iyer S, Halkin A, Vitek J, Brennan C. Realizing the potential of carotid artery stenting: proposed paradigms for patient selection and procedural technique. Circulation. 2006;113:2021–30.

    Article  PubMed  Google Scholar 

  51. Sillesen H. What does ‘best medical therapy’ really mean? Eur J Vasc Endovasc Surg. 2008;35:139–44.

    Article  CAS  PubMed  Google Scholar 

  52. Wright JM, Musini VM. First-line drugs for hypertension. The Cochrane Database of Systematic Reviews 2009:Cd001841.

  53. Chimowitz MI, Lynn MJ, Derdeyn CP, et al. Stenting versus aggressive medical therapy for intracranial arterial stenosis. N Engl J Med. 2011;365:993–1003. First large-scale stroke prevention study demonstrating the value of multi-faceted aggressive medical therapy.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  54. Zaidat OO, Fitzsimmons BF, Woodward BK, et al. Effect of a balloon-expandable intracranial stent vs medical therapy on risk of stroke in patients with symptomatic intracranial stenosis: the VISSIT randomized clinical trial. JAMA. 2015;313:1240–8.

    Article  CAS  PubMed  Google Scholar 

  55. Merwick A, Albers GW, Arsava EM, et al. Reduction in early stroke risk in carotid stenosis with transient ischemic attack associated with statin treatment. Stroke J Cereb Circ. 2013;44:2814–20.

    Article  CAS  Google Scholar 

  56. Shahidi S, Owen-Falkenberg A, Hjerpsted U, Rai A, Ellemann K. Urgent best medical therapy may obviate the need for urgent surgery in patients with symptomatic carotid stenosis. Stroke J Cereb Circ. 2013;44:2220–5.

    Article  Google Scholar 

  57. Marquardt L, Geraghty OC, Mehta Z, Rothwell PM. Low risk of ipsilateral stroke in patients with asymptomatic carotid stenosis on best medical treatment: a prospective, population-based study. Stroke J Cereb Circ. 2010;41:e11–7.

    Article  Google Scholar 

  58. den Hartog AG, Achterberg S, Moll FL, et al. Asymptomatic carotid artery stenosis and the risk of ischemic stroke according to subtype in patients with clinical manifest arterial disease. Stroke J Cereb Circ. 2013;44:1002–7.

    Article  Google Scholar 

  59. Spence JD, Coates V, Li H, et al. Effects of intensive medical therapy on microemboli and cardiovascular risk in asymptomatic carotid stenosis. Arch Neurol. 2010;67:180–6. Important study showing the use of emboli monitoring for risk stratification and the effects of medical therapy.

    Article  PubMed  Google Scholar 

  60. Pahigiannis K, Kaufmann P, Koroshetz W. Carotid intervention: is it warranted in asymptomatic individuals if risk factors are aggressively managed? Stroke J Cereb Circ. 2014;45:e40–1.

    Article  Google Scholar 

  61. Reiff T, Eckstein HH, Amiri H, Hacke W, Ringleb PA. Modification of SPACE-2 study design. Int J Stroke. 2014;9:E12–3.

    Article  CAS  PubMed  Google Scholar 

  62. Balestrini S, Perozzi C, Altamura C, et al. Severe carotid stenosis and impaired cerebral hemodynamics can influence cognitive deterioration. Neurology. 2013;80:2145–50.

    Article  PubMed  Google Scholar 

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Compliance with Ethics Guidelines

Conflict of Interest

Priyank Khandelwal declares that he has no conflict of interest. Seemant Chaturvedi is a member of the Executive Committee for the CREST 2 and ACT 1 studies. He is also Chair of the Stroke adjudication committee for the CREST study.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

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Authors and Affiliations

  1. Department of Neurology and Stroke Program, University of Miami Miller School of Medicine, 1120 NW 14th St., Room 1363, Miami, FL, 33136, USA

    Priyank Khandelwal & Seemant Chaturvedi

  2. Miami Veterans Affairs Hospital, Miami, USA

    Seemant Chaturvedi

Authors
  1. Priyank Khandelwal
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  2. Seemant Chaturvedi
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Correspondence to Seemant Chaturvedi.

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This article is part of the Topical Collection on Stroke

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Khandelwal, P., Chaturvedi, S. Carotid Disease Management: Surgery, Stenting, or Medication. Curr Cardiol Rep 17, 70 (2015). https://doi.org/10.1007/s11886-015-0625-5

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