Abstract
Carotid artery stenosis is associated with the risk of stroke, myocardial infarction, and vascular death. In selected patients, revascularization of carotid narrowing by endarterectomy may reduce the risk of stroke distal to the stenosis. Carotid artery stenting has evolved as a potential alternative to endarterectomy. Four randomized clinical trials comparing safety and efficacy of endarterectomy versus stenting of symptomatic carotid stenosis have been published in recent years, but there remains some uncertainty about the implications of these trials for clinical routine. Both carotid stenting and endarterectomy are based on different treatment strategies which may result in different specific risk factors associated with each procedure. Hence, the procedural risk of either modality varies not only with the skills of the surgeon or the interventionalist but may depend on patient characteristics. It appears that the most important question is not whether one revascularization modality is superior but for which patient one modality is better than the other. A comprehensive diagnostic workup of patients with carotid stenosis based on a broad panel of covariates that affect the risk of vascular events may improve selection of patients for carotid revascularization and may help to decide for whom one revascularization modality is likely to be better than the other.
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References
Rothwell PM, Eliasziw M, Gutnikov SA, Fox AJ, Taylor DW, Mayberg MR, Warlow CP, Barnett HJ (2003) Analysis of pooled data from the randomised controlled trials of endarterectomy for symptomatic carotid stenosis. Lancet 361:107–116
Barnett HJ, Gunton RW, Eliasziw M, Fleming L, Sharpe B, Gates P, Meldrum H (2000) Causes and severity of ischemic stroke in patients with internal carotid artery stenosis. JAMA 283:1429–1436
Chimowitz MI, Weiss DG, Cohen SL, Starling MR, Hobson RW 2nd (1994) Cardiac prognosis of patients with carotid stenosis and no history of coronary artery disease. Veterans Affairs Cooperative Study Group 167. Stroke 25:759–765
European Carotid Surgery Trialists' Collaborative Group (1991) MRC European Carotid Surgery Trial: interim results for symptomatic patients with severe (70–99%) or with mild (0–29%) carotid stenosis. Lancet 337:1235–1243
Ferguson GG, Eliasziw M, Barr HW, Clagett GP, Barnes RW, Wallace MC, Taylor DW, Haynes RB, Finan JW, Hachinski VC, Barnett HJ (1999) The North American symptomatic carotid endarterectomy trial: surgical results in 1415 patients. Stroke 30:1751–1758
North American Symptomatic Carotid Endarterectomy Trial Collaborators (1991) Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med 325:445–453
Fox AJ (1993) How to measure carotid stenosis. Radiology 186:316–318
European Carotid Surgery Trialists’ Collaborative Group (1998) Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST). Lancet 351:1379–1387
Stingele R, Berger J, Alfke K, Eckstein HH, Fraedrich G, Allenberg J, Hartmann M, Ringleb PA, Fiehler J, Bruckmann H, Hennerici M, Jansen O, Klein G, Kunze A, Marx P, Niederkorn K, Schmiedt W, Solymosi L, Zeumer H, Hacke W (2008) Clinical and angiographic risk factors for stroke and death within 30 days after carotid endarterectomy and stent-protected angioplasty: a subanalysis of the SPACE study. Lancet Neurol 7:216–222
Rothwell PM, Warlow CP (2000) Low risk of ischemic stroke in patients with reduced internal carotid artery lumen diameter distal to severe symptomatic carotid stenosis: cerebral protection due to low poststenotic flow? On behalf of the European Carotid Surgery Trialists’ Collaborative Group. Stroke 31:622–630
Morgenstern LB, Fox AJ, Sharpe BL, Eliasziw M, Barnett HJ, Grotta JC (1997) The risks and benefits of carotid endarterectomy in patients with near occlusion of the carotid artery. North American Symptomatic Carotid Endarterectomy Trial (NASCET) Group. Neurology 48:911–915
Fox AJ, Eliasziw M, Rothwell PM, Schmidt MH, Warlow CP, Barnett HJ (2005) Identification, prognosis, and management of patients with carotid artery near occlusion. AJNR Am J Neuroradiol 26:2086–2094
Executive Committee for the Asymptomatic Carotid Atherosclerosis Study (1995) Endarterectomy for asymptomatic carotid artery stenosis. JAMA 273:1421–1428
Halliday A, Mansfield A, Marro J, Peto C, Peto R, Potter J, Thomas D (2004) Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomised controlled trial. Lancet 363:1491–1502
Streifler JY, Eliasziw M, Benavente OR, Harbison JW, Hachinski VC, Barnett HJ, Simard D (1995) The risk of stroke in patients with first-ever retinal vs hemispheric transient ischemic attacks and high-grade carotid stenosis. North American Symptomatic Carotid Endarterectomy Trial. Arch Neurol 52:246–249
Marquardt L, Geraghty OC, Mehta Z, Rothwell PM (2010) Low risk of ipsilateral stroke in patients with asymptomatic carotid stenosis on best medical treatment. A prospective, population-based study. Stroke 41(1):e11–e17
Cohen SN, Hobson RW 2nd, Weiss DG, Chimowitz M (1993) Death associated with asymptomatic carotid artery stenosis: long-term clinical evaluation. VA Cooperative Study 167 Group. J Vasc Surg 18:1002–1009, discussion 1009–1011
Inzitari D, Eliasziw M, Sharpe BL, Fox AJ, Barnett HJ (2000) Risk factors and outcome of patients with carotid artery stenosis presenting with lacunar stroke. North American Symptomatic Carotid Endarterectomy Trial Group. Neurology 54:660–666
Rothwell PM (2004) ACST: which subgroups will benefit most from carotid endarterectomy? Lancet 364:1122–1123, author reply 1125–1126
Reiff T, Stingele R, Eckstein HH, Fraedrich G, Jansen O, Mudra H, Mansmann U, Hacke W, Ringleb P (2009) Stent-protected angioplasty in asymptomatic carotid artery stenosis vs. endarterectomy: SPACE2—a three-arm randomised-controlled clinical trial. Int J Stroke 4:294–299
Bond R, Rerkasem K, Rothwell PM (2003) Systematic review of the risks of carotid endarterectomy in relation to the clinical indication for and timing of surgery. Stroke 34:2290–2301
Eliasziw M, Streifler JY, Spence JD, Fox AJ, Hachinski VC, Barnett HJ (1995) Prognosis for patients following a transient ischemic attack with and without a cerebral infarction on brain CT. North American Symptomatic Carotid Endarterectomy Trial (NASCET) Group. Neurology 45:428–431
Lovett JK, Coull AJ, Rothwell PM (2004) Early risk of recurrence by subtype of ischemic stroke in population-based incidence studies. Neurology 62:569–573
Fairhead JF, Mehta Z, Rothwell PM (2005) Population-based study of delays in carotid imaging and surgery and the risk of recurrent stroke. Neurology 65:371–375
Johnston SC, Rothwell PM, Nguyen-Huynh MN, Giles MF, Elkins JS, Bernstein AL, Sidney S (2007) Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack. Lancet 369:283–292
Rothwell PM, Giles MF, Flossmann E, Lovelock CE, Redgrave JN, Warlow CP, Mehta Z (2005) A simple score (ABCD) to identify individuals at high early risk of stroke after transient ischaemic attack. Lancet 366:29–36
Johnston SC, Gress DR, Browner WS, Sidney S (2000) Short-term prognosis after emergency department diagnosis of TIA. JAMA 284:2901–2906
Rothwell PM, Giles MF, Chandratheva A, Marquardt L, Geraghty O, Redgrave JN, Lovelock CE, Binney LE, Bull LM, Cuthbertson FC, Welch SJ, Bosch S, Alexander FC, Silver LE, Gutnikov SA, Mehta Z (2007) Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (EXPRESS study): a prospective population-based sequential comparison. Lancet 370:1432–1442
Kastrup A, Ernemann U, Nagele T, Groschel K (2006) Risk factors for early recurrent cerebral ischemia before treatment of symptomatic carotid stenosis. Stroke 37:3032–3034
Rothwell PM, Eliasziw M, Gutnikov SA, Warlow CP, Barnett HJ (2004) Endarterectomy for symptomatic carotid stenosis in relation to clinical subgroups and timing of surgery. Lancet 363:915–924
Barnett HJ, Taylor DW, Eliasziw M, Fox AJ, Ferguson GG, Haynes RB, Rankin RN, Clagett GP, Hachinski VC, Sackett DL, Thorpe KE, Meldrum HE, Spence JD (1998) Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med 339:1415–1425
Davies KN, Humphrey PR (1993) Complications of cerebral angiography in patients with symptomatic carotid territory ischaemia screened by carotid ultrasound. J Neurol Neurosurg Psychiatry 56:967–972
Bendszus M, Koltzenburg M, Burger R, Warmuth-Metz M, Hofmann E, Solymosi L (1999) Silent embolism in diagnostic cerebral angiography and neurointerventional procedures: a prospective study. Lancet 354:1594–1597
Leys D, Ringelstein EB, Kaste M, Hacke W (2007) Facilities available in European hospitals treating stroke patients. Stroke 38:2985–2991
Wardlaw JM, Chappell FM, Best JJ, Wartolowska K, Berry E (2006) Non-invasive imaging compared with intra-arterial angiography in the diagnosis of symptomatic carotid stenosis: a meta-analysis. Lancet 367:1503–1512
Eckstein HH, Winter R, Eichbaum M, Klemm K, Schumacher H, Dorfler A, Schulte K, Neuwirth A, Gross W, Schnabel P, Allenberg JR (2001) Grading of internal carotid artery stenosis: validation of Doppler/duplex ultrasound criteria and angiography against endarterectomy specimen. Eur J Vasc Endovasc Surg 21:301–310
Shaalan WE, Wahlgren CM, Desai T, Piano G, Skelly C, Bassiouny HS (2008) Reappraisal of velocity criteria for carotid bulb/internal carotid artery stenosis utilizing high-resolution B-mode ultrasound validated with computed tomography angiography. J Vasc Surg 48:104–112, discussion 112–103
Wardlaw JM, Stevenson MD, Chappell F, Rothwell PM, Gillard J, Young G, Thomas SM, Roditi G, Gough MJ (2009) Carotid artery imaging for secondary stroke prevention: both imaging modality and rapid access to imaging are important. Stroke 40:3511–3517
Markus HS, MacKinnon A (2005) Asymptomatic embolization detected by Doppler ultrasound predicts stroke risk in symptomatic carotid artery stenosis. Stroke 36:971–975
Biasi GM, Froio A, Diethrich EB, Deleo G, Galimberti S, Mingazzini P, Nicolaides AN, Griffin M, Raithel D, Reid DB, Valsecchi MG (2004) Carotid plaque echolucency increases the risk of stroke in carotid stenting: the Imaging in Carotid Angioplasty and Risk of Stroke (ICAROS) study. Circulation 110:756–762
Rosenkranz M, Wittkugel O, Waiblinger C, Thomalla G, Krutzelmann A, Havemeister S, Zeumer H, Gerloff C, Fiehler J (2009) Cerebral embolism during carotid artery stenting: role of carotid plaque echolucency. Cerebrovasc Dis 27:443–449
Saba L, Sanfilippo R, Montisci R, Mallarini G (2010) Carotid artery wall thickness: comparison between sonography and multi-detector row CT angiography. Neuroradiology 52:75–82
Wardlaw JM, Chappell FM, Stevenson M, De Nigris E, Thomas S, Gillard J, Berry E, Young G, Rothwell P, Roditi G, Gough M, Brennan A, Bamford J, Best J (2006) Accurate, practical and cost-effective assessment of carotid stenosis in the UK. Health Technol Assess 10: iii–iv, ix–x, 1–182.
Eliasziw M, Streifler JY, Fox AJ, Hachinski VC, Ferguson GG, Barnett HJ (1994) Significance of plaque ulceration in symptomatic patients with high-grade carotid stenosis. North American Symptomatic Carotid Endarterectomy Trial. Stroke 25:304–308
Rothwell PM, Gibson R, Warlow CP (2000) Interrelation between plaque surface morphology and degree of stenosis on carotid angiograms and the risk of ischemic stroke in patients with symptomatic carotid stenosis. On behalf of the European Carotid Surgery Trialists’ Collaborative Group. Stroke 31:615–621
Golledge J, Greenhalgh RM, Davies AH (2000) The symptomatic carotid plaque. Stroke 31:774–781
Rothwell PM, Villagra R, Gibson R, Donders RC, Warlow CP (2000) Evidence of a chronic systemic cause of instability of atherosclerotic plaques. Lancet 355:19–24
Gronholdt ML, Nordestgaard BG, Schroeder TV, Vorstrup S, Sillesen H (2001) Ultrasonic echolucent carotid plaques predict future strokes. Circulation 104:68–73
Mathiesen EB, Bonaa KH, Joakimsen O (2001) Echolucent plaques are associated with high risk of ischemic cerebrovascular events in carotid stenosis: the Tromso study. Circulation 103:2171–2175
El-Barghouty NM, Levine T, Ladva S, Flanagan A, Nicolaides A (1996) Histological verification of computerised carotid plaque characterisation. Eur J Vasc Endovasc Surg 11:414–416
Gronholdt ML, Nordestgaard BG, Wiebe BM, Wilhjelm JE, Sillesen H (1998) Echo-lucency of computerized ultrasound images of carotid atherosclerotic plaques are associated with increased levels of triglyceride-rich lipoproteins as well as increased plaque lipid content. Circulation 97:34–40
Narumi S, Sasaki M, Ohba H, Ogasawara K, Hitomi J, Mori K, Ohura K, Ono A, Terayama Y (2010) Altered carotid plaque signal among different repetition times on T1-weighted magnetic resonance plaque imaging with self-navigated radial-scan technique. Neuroradiology 52:285–290
Sakamoto M, Taoka T, Nakagawa H, Takayama K, Wada T, Myouchin K, Akashi T, Miyasaka T, Fukusumi A, Iwasaki S, Kichikawa K (2010) Magnetic resonance plaque imaging to predict the occurrence of the slow-flow phenomenon in carotid artery stenting procedures. Neuroradiology 52(4):275–283
Watanabe Y, Nagayama M (2010) MR plaque imaging of the carotid artery. Neuroradiology 52(4):253–274
Esposito L, Sievers M, Sander D, Heider P, Wolf O, Greil O, Zimmer C, Poppert H (2007) Detection of unstable carotid artery stenosis using MRI. J Neurol 254:1714–1722
Siebler M, Nachtmann A, Sitzer M, Rose G, Kleinschmidt A, Rademacher J, Steinmetz H (1995) Cerebral microembolism and the risk of ischemia in asymptomatic high-grade internal carotid artery stenosis. Stroke 26:2184–2186
Valton L, Larrue V, le Traon AP, Massabuau P, Geraud G (1998) Microembolic signals and risk of early recurrence in patients with stroke or transient ischemic attack. Stroke 29:2125–2128
Molloy J, Markus HS (1999) Asymptomatic embolization predicts stroke and TIA risk in patients with carotid artery stenosis. Stroke 30:1440–1443
Markus HS, Clifton A, Buckenham T, Brown MM (1994) Carotid angioplasty. Detection of embolic signals during and after the procedure. Stroke 25:2403–2406
Jordan WD Jr, Voellinger DC, Doblar DD, Plyushcheva NP, Fisher WS, McDowell HA (1999) Microemboli detected by transcranial Doppler monitoring in patients during carotid angioplasty versus carotid endarterectomy. Cardiovasc Surg 7:33–38
Orlandi G, Fanucchi S, Fioretti C, Acerbi G, Puglioli M, Padolecchia R, Sartucci F, Murri L (2001) Characteristics of cerebral microembolism during carotid stenting and angioplasty alone. Arch Neurol 58:1410–1413
Markus HS, Droste DW, Kaps M, Larrue V, Lees KR, Siebler M, Ringelstein EB (2005) Dual antiplatelet therapy with clopidogrel and aspirin in symptomatic carotid stenosis evaluated using doppler embolic signal detection: the Clopidogrel and Aspirin for Reduction of Emboli in Symptomatic Carotid Stenosis (CARESS) trial. Circulation 111:2233–2240
Spence JD, Coates V, Li H, Tamayo A, Munoz C, Hackam DG, Dicicco M, Desroches J, Bogiatzi C, Klein J, Madrenas J, Hegele RA (2010) Effects of intensive medical therapy on microemboli and cardiovascular risk in asymptomatic carotid stenosis. Arch Neurol 67(2):180–186
Pelisek J, Rudelius M, Zepper P, Poppert H, Reeps C, Schuster T, Eckstein HH (2009) Multiple biological predictors for vulnerable carotid lesions. Cerebrovasc Dis 28:601–610
Gasecki AP, Eliasziw M, Ferguson GG, Hachinski V, Barnett HJ (1995) Long-term prognosis and effect of endarterectomy in patients with symptomatic severe carotid stenosis and contralateral carotid stenosis or occlusion: results from NASCET. North American Symptomatic Carotid Endarterectomy Trial (NASCET) Group. J Neurosurg 83:778–782
Rothwell PM, Slattery J, Warlow CP (1997) Clinical and angiographic predictors of stroke and death from carotid endarterectomy: systematic review. BMJ 315:1571–1577
Kappelle LJ, Eliasziw M, Fox AJ, Sharpe BL, Barnett HJ (1999) Importance of intracranial atherosclerotic disease in patients with symptomatic stenosis of the internal carotid artery. The North American Symptomatic Carotid Endarterectomy Trail. Stroke 30:282–286
Kappelle LJ, Eliasziw M, Fox AJ, Barnett HJ (2000) Small, unruptured intracranial aneurysms and management of symptomatic carotid artery stenosis. North American Symptomatic Carotid Endarterectomy Trial Group. Neurology 55:307–309
Bond R, Rerkasem K, Cuffe R, Rothwell PM (2005) A systematic review of the associations between age and sex and the operative risks of carotid endarterectomy. Cerebrovasc Dis 20:69–77
Alamowitch S, Eliasziw M, Algra A, Meldrum H, Barnett HJ (2001) Risk, causes, and prevention of ischaemic stroke in elderly patients with symptomatic internal-carotid-artery stenosis. Lancet 357:1154–1160
Clark WM, on behalf of the CREST Investigators (2010) Carotid revascularization endarterectomy versus stenting trial. International Stroke Conference 2010, San Antonio
Mas JL, Chatellier G, Beyssen B, Branchereau A, Moulin T, Becquemin JP, Larrue V, Lievre M, Leys D, Bonneville JF, Watelet J, Pruvo JP, Albucher JF, Viguier A, Piquet P, Garnier P, Viader F, Touze E, Giroud M, Hosseini H, Pillet JC, Favrole P, Neau JP, Ducrocq X (2006) Endarterectomy versus stenting in patients with symptomatic severe carotid stenosis. N Engl J Med 355:1660–1671
International Carotid Stenting Study investigators (2010) 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 375(9719):985–997
Ringleb PA, Allenberg J, Bruckmann H, Eckstein HH, Fraedrich G, Hartmann M, Hennerici M, Jansen O, Klein G, Kunze A, Marx P, Niederkorn K, Schmiedt W, Solymosi L, Stingele R, Zeumer H, Hacke W (2006) 30 day results from the SPACE trial of stent-protected angioplasty versus carotid endarterectomy in symptomatic patients: a randomised non-inferiority trial. Lancet 368:1239–1247
Fiehler J, Jansen O, Berger J, Eckstein HH, Ringleb PA, Stingele R (2008) Differences in complication rates among the centres in the SPACE study. Neuroradiology 50:1049–1053
Hobson RW 2nd (2000) CREST (Carotid Revascularization Endarterectomy versus Stent Trial): background, design, and current status. Semin Vasc Surg 13:139–143
Bangalore S et al (2009) Carotid endarterectomy versus carotid artery stenting: insights from a propensity-matched analysis of the Reduction of Atherothrombosis for Continued Health (REACH) registry. Circulation 120:S954–955
Rothwell PM (2007) Current status of carotid endarterectomy and stenting for symptomatic carotid stenosis. Cerebrovasc Dis 24(Suppl 1):116–125
Rothwell PM (2005) Risk modeling to identify patients with symptomatic carotid stenosis most at risk of stroke. Neurol Res 27(Suppl 1):S18–28
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Rosenkranz, M., Gerloff, C. Diagnostic workup in carotid stenosis—a neurologist’s perspective. Neuroradiology 52, 619–628 (2010). https://doi.org/10.1007/s00234-010-0692-7
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DOI: https://doi.org/10.1007/s00234-010-0692-7