Hans-Henning Eckstein1, Andreas Kühnl, Joachim Berkefeld, Holger Lawall, Martin Storck, Dirk Sander. 1. Spokesman (HHE) and Secretary (AK) of the Steering Group, Department forf Vascular and Endovascular Surgery, University Hospital "rechts der Isar", Technical University of Munich; Member of the Steering Group, Institute for Neuroradiology, University Hospital Frankfurt; Member of the Steering Group, Ettlingen; Member of the Steering Group, Department of Vascular and Thoracic Surgery, Karlsruhe Municipal Hospital Member of the Steering Group, Department of Neurology and Stroke Unit, Benedictus Hospital Tutzing; German Vascular Society (DGG); German Society of Neuroradiology (DGNR); German Society for Angiology/Vascular Medicine (DGA); German Society of Surgery (DGCH); German Society of Neurology (DGN).
Abstract
BACKGROUND: Around 15% of cerebral ischemias are caused by lesions of the extracranial carotid artery. The goal of this guideline is to provide evidence- and consensus-based recommendations for the management of patients with extracranial carotid stenoses throughout Germany and Austria. METHODS: A systematic literature search (1990-2019) and methodical assessment of existing guidelines and systematic reviews; consensus-based answers to 37 key questions with evidence-based recommendations. RESULTS: The prevalence of extracranial carotid artery stenoses is around 4% overall, higher from the age of 65 years. The most important examination modality is duplex sonography. Randomized trials have shown that carotid endarterectomy (CEA) significantly reduces the 5-year risk of stroke in patients with 60-99 % asymptomatic stenoses (absolute risk reduction [ARR] 4.1% over 5 years, number needed to treat [NNT] 24) or 50-99% symptomatic stenoses (50-69%: ARR 4.6 % over 5 years, NNT 22; 70-99%: 15.9 % over 5 years, NNT 6). With the aid of intensive conservative treatment, the carotid artery-associated risk of stroke can be reduced to as little as 1% per year. Critical determination of indications and strict quality criteria are therefore necessary for CEA and carotid artery stenting (CAS). Systematic reviews of controlled trials comparing CEA and CAS show that the procedural risk of stroke is higher for CAS (asymptomatic: 2.6% versus 1.3%; symptomatic: 6.2% versus 3.8%). There are no differences in the long term. CEA is recommended as standard procedure for high-grade asymptomatic and moderate to high-grade symptomatic carotid artery stenoses; CAS may be considered as an alternative. For both procedures, the periprocedural combined rate of stroke or death should not exceed 2% for asymptomatic stenoses or 4% for symptomatic stenoses. CONCLUSION: Future studies should evaluate even better selection criteria for optimal individualized treatment, whether conservative, surgical, or endovascular.
BACKGROUND: Around 15% of cerebral ischemias are caused by lesions of the extracranial carotid artery. The goal of this guideline is to provide evidence- and consensus-based recommendations for the management of patients with extracranial carotid stenoses throughout Germany and Austria. METHODS: A systematic literature search (1990-2019) and methodical assessment of existing guidelines and systematic reviews; consensus-based answers to 37 key questions with evidence-based recommendations. RESULTS: The prevalence of extracranial carotid artery stenoses is around 4% overall, higher from the age of 65 years. The most important examination modality is duplex sonography. Randomized trials have shown that carotid endarterectomy (CEA) significantly reduces the 5-year risk of stroke in patients with 60-99 % asymptomatic stenoses (absolute risk reduction [ARR] 4.1% over 5 years, number needed to treat [NNT] 24) or 50-99% symptomatic stenoses (50-69%: ARR 4.6 % over 5 years, NNT 22; 70-99%: 15.9 % over 5 years, NNT 6). With the aid of intensive conservative treatment, the carotid artery-associated risk of stroke can be reduced to as little as 1% per year. Critical determination of indications and strict quality criteria are therefore necessary for CEA and carotid artery stenting (CAS). Systematic reviews of controlled trials comparing CEA and CAS show that the procedural risk of stroke is higher for CAS (asymptomatic: 2.6% versus 1.3%; symptomatic: 6.2% versus 3.8%). There are no differences in the long term. CEA is recommended as standard procedure for high-grade asymptomatic and moderate to high-grade symptomatic carotid artery stenoses; CAS may be considered as an alternative. For both procedures, the periprocedural combined rate of stroke or death should not exceed 2% for asymptomatic stenoses or 4% for symptomatic stenoses. CONCLUSION: Future studies should evaluate even better selection criteria for optimal individualized treatment, whether conservative, surgical, or endovascular.
Authors: Michiel H F Poorthuis; Eelco C Brand; Alison Halliday; Richard Bulbulia; Michiel L Bots; Gert J de Borst Journal: Ann Surg Date: 2019-08 Impact factor: 12.969
Authors: Steen Dalby Kristensen; Juhani Knuuti; Antti Saraste; Stefan Anker; Hans Erik Bøtker; Stefan De Hert; Ian Ford; Jose Ramón Gonzalez Juanatey; Bulent Gorenek; Guy Robert Heyndrickx; Andreas Hoeft; Kurt Huber; Bernard Iung; Keld Per Kjeldsen; Dan Longrois; Thomas F Luescher; Luc Pierard; Stuart Pocock; Susanna Price; Marco Roffi; Per Anton Sirnes; Miguel Sousa Uva; Vasilis Voudris; Christian Funck-Brentano Journal: Eur J Anaesthesiol Date: 2014-10 Impact factor: 4.330
Authors: A R Naylor; J-B Ricco; G J de Borst; S Debus; J de Haro; A Halliday; G Hamilton; J Kakisis; S Kakkos; S Lepidi; H S Markus; D J McCabe; J Roy; H Sillesen; J C van den Berg; F Vermassen; P Kolh; N Chakfe; R J Hinchliffe; I Koncar; J S Lindholt; M Vega de Ceniga; F Verzini; J Archie; S Bellmunt; A Chaudhuri; M Koelemay; A-K Lindahl; F Padberg; M Venermo Journal: Eur J Vasc Endovasc Surg Date: 2017-08-26 Impact factor: 7.069
Authors: Walter N Kernan; Bruce Ovbiagele; Henry R Black; Dawn M Bravata; Marc I Chimowitz; Michael D Ezekowitz; Margaret C Fang; Marc Fisher; Karen L Furie; Donald V Heck; S Claiborne Clay Johnston; Scott E Kasner; Steven J Kittner; Pamela H Mitchell; Michael W Rich; DeJuran Richardson; Lee H Schwamm; John A Wilson Journal: Stroke Date: 2014-05-01 Impact factor: 7.914
Authors: Christoph Knappich; Andreas Kuehnl; Bernhard Haller; Michael Salvermoser; Ale Algra; Jean-Pierre Becquemin; Leo H Bonati; Richard Bulbulia; David Calvet; Gustav Fraedrich; John Gregson; Alison Halliday; Jeroen Hendrikse; George Howard; Olav Jansen; Mahmoud B Malas; Peter A Ringleb; Martin M Brown; Jean-Louis Mas; Thomas G Brott; Dylan R Morris; Steff C Lewis; Hans-Henning Eckstein Journal: Stroke Date: 2019-11-18 Impact factor: 7.914
Authors: James F Meschia; Cheryl Bushnell; Bernadette Boden-Albala; Lynne T Braun; Dawn M Bravata; Seemant Chaturvedi; Mark A Creager; Robert H Eckel; Mitchell S V Elkind; Myriam Fornage; Larry B Goldstein; Steven M Greenberg; Susanna E Horvath; Costantino Iadecola; Edward C Jauch; Wesley S Moore; John A Wilson Journal: Stroke Date: 2014-10-28 Impact factor: 7.914
Authors: Alison Halliday; Michael Harrison; Elizabeth Hayter; Xiangling Kong; Averil Mansfield; Joanna Marro; Hongchao Pan; Richard Peto; John Potter; Kazem Rahimi; Angela Rau; Steven Robertson; Jonathan Streifler; Dafydd Thomas Journal: Lancet Date: 2010-09-25 Impact factor: 79.321
Authors: Leo H Bonati; Stavros Kakkos; Joachim Berkefeld; Gert J de Borst; Richard Bulbulia; Alison Halliday; Isabelle van Herzeele; Igor Koncar; Dominick Jh McCabe; Avtar Lal; Jean-Baptiste Ricco; Peter Ringleb; Martin Taylor-Rowan; Hans-Henning Eckstein Journal: Eur Stroke J Date: 2021-05-11
Authors: Johannes M Weller; Franziska Dorn; Julius N Meissner; Sebastian Stösser; Niklas M Beckonert; Julia Nordsiek; Christine Kindler; Christoph Riegler; Fee Keil; Gabor C Petzold; Felix J Bode Journal: Neurol Res Pract Date: 2022-09-12