Kosmas I Paraskevas1, Dimitri P Mikhailidis2, Pier Luigi Antignani3, Hediyeh Baradaran4, Reinoud P H Bokkers5, Richard P Cambria6, Alan Dardik7, Alun H Davies8, Hans-Henning Eckstein9, Gianluca Faggioli10, Jose Fernandes E Fernandes11, Gustav Fraedrich12, George Geroulakos13, Peter Gloviczki14, Jonathan Golledge15, Ajay Gupta16, Mateja K Jezovnik17, Stavros K Kakkos18, Niki Katsiki19, Michael Knoflach20, M Eline Kooi21, Gaetano Lanza22, Christos D Liapis23, Ian M Loftus24, Armando Mansilha25, Antoine Millon26, Andrew N Nicolaides27, Rodolfo Pini10, Pavel Poredos28, Jean-Baptiste Ricco29, Thomas S Riles30, Peter Arthur Ringleb31, Tatjana Rundek32, Luca Saba33, Felix Schlachetzki34, Mauro Silvestrini35, Francesco Spinelli36, Francesco Stilo36, Sherif Sultan37, Jasjit S Suri38, Clark J Zeebregts39, Seemant Chaturvedi40. 1. Department of Vascular Surgery, Central Clinic of Athens, 24, Alexander Papagou street, N. Iraklio, Athens 14122, Greece. Electronic address: paraskevask@hotmail.com. 2. Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, UK. 3. Vascular Center, Nuova Villa Claudia, Rome, Italy. 4. Department of Radiology, University of Utah, Salt Lake City, UT, United States. 5. Department of Radiology, Medical Imaging Center, University Medical Center Groningen, Groningen, the Netherland. 6. Division of Vascular and Endovascular Surgery, St. Elizabeth's Medical Center, Brighton, MA, United States. 7. Division of Vascular and Endovascular Surgery, Yale University School of Medicine, New Haven, CT, United States. 8. Section of Vascular Surgery, Imperial College and Imperial Healthcare NHS Trust, London, UK. 9. Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany. 10. Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola Malpighi, Bologna, Italy. 11. Department of Vascular Surgery, University of Lisbon, Lisbon Academic Medical Center, Lisbon, Portugal. 12. Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria. 13. Department of Vascular Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece. 14. Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, United States. 15. Queensland Research Center for Peripheral Vascular Disease, James Cook University, Townsville University Hospital, Townsville, Queensland, Australia. 16. Department of Radiology, Weill Cornell Medicine, New York, United States. 17. Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Center, Houston, TX, United States. 18. Department of Vascular Surgery, University of Patras Medical School, Patras, Greece. 19. First Department of Internal Medicine, AHEPA University Hospital, Thessaloniki, Greece. 20. Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria. 21. CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, the Netherland; Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, the Netherland. 22. Vascular Surgery Department, IRCSS MultiMedica Hospital, Castellanza, Italy. 23. Athens Vascular Research Center, Athens, Greece. 24. St. George's Vascular Institute, St. George's University of London, London, UK. 25. Faculty of Medicine of the University of Porto, Porto, Portugal; Department of Angiology and Vascular Surgery, Hospital de S. Joao, Porto, Portugal. 26. Department of Vascular and Endovascular Surgery, Louis Pradel Hospital, Hospices Civils de Lyon, France. 27. Department of Surgery, University of Nicosia Medical School, Nicosia, Cyprus. 28. Department of Vascular Disease, University Medical Center, Ljubljana, Slovenia. 29. Department of Clinical Research, University of Poitiers, CHU de Poitiers, Poitiers, France. 30. Department of Surgery, Division of Vascular Surgery, New York University, Langone Medical Center, New York, United States. 31. Department of Neurology, University Hospital Heidelberg, Germany. 32. Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, United States. 33. Department of Radiology, Azienda Ospedaliera Universitaria Di Cagliari, Cagliari, Italy. 34. Department of Neurology, University of Regensburg, Regensburg, Germany. 35. Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy. 36. Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy. 37. Department of Vascular and Endovascular Surgery, Western Vascular Institute, University Hospital Galway, National University of Ireland, Galway, Ireland. 38. Stroke Diagnosis and Monitoring Division, AtheroPointTM, Roseville, United States. 39. Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherland. 40. Department of Neurology and Stroke Program, University of Maryland School of Medicine, Baltimore, MD, United States.
Abstract
OBJECTIVES: The recommendations of international guidelines for the management of asymptomatic carotid stenosis (ACS) often vary considerably and extend from a conservative approach with risk factor modification and best medical treatment (BMT) alone, to a more aggressive approach with a carotid intervention plus BMT. The aim of the current multispecialty position statement is to reconcile the conflicting views on the topic. MATERIALS AND METHODS: A literature review was performed with a focus on data from recent studies. RESULTS: Several clinical and imaging high-risk features have been identified that are associated with an increased long-term ipsilateral ischemic stroke risk in patients with ACS. Such high-risk clinical/imaging features include intraplaque hemorrhage, impaired cerebrovascular reserve, carotid plaque echolucency/ulceration/ neovascularization, a lipid-rich necrotic core, a thin or ruptured fibrous cap, silent brain infarction, a contralateral transient ischemic attack/stroke episode, male patients < 75 years and microembolic signals on transcranial Doppler. There is growing evidence that 80-99% ACS indicate a higher stroke risk than 50-79% stenoses. CONCLUSIONS: Although aggressive risk factor control and BMT should be implemented in all ACS patients, several high-risk features that may increase the risk of a future cerebrovascular event are now documented. Consequently, some guidelines recommend a prophylactic carotid intervention in high-risk patients to prevent future cerebrovascular events. Until the results of the much-anticipated randomized controlled trials emerge, the jury is still out regarding the optimal management of ACS patients.
OBJECTIVES: The recommendations of international guidelines for the management of asymptomatic carotid stenosis (ACS) often vary considerably and extend from a conservative approach with risk factor modification and best medical treatment (BMT) alone, to a more aggressive approach with a carotid intervention plus BMT. The aim of the current multispecialty position statement is to reconcile the conflicting views on the topic. MATERIALS AND METHODS: A literature review was performed with a focus on data from recent studies. RESULTS: Several clinical and imaging high-risk features have been identified that are associated with an increased long-term ipsilateral ischemic stroke risk in patients with ACS. Such high-risk clinical/imaging features include intraplaque hemorrhage, impaired cerebrovascular reserve, carotid plaque echolucency/ulceration/ neovascularization, a lipid-rich necrotic core, a thin or ruptured fibrous cap, silent brain infarction, a contralateral transient ischemic attack/stroke episode, male patients < 75 years and microembolic signals on transcranial Doppler. There is growing evidence that 80-99% ACS indicate a higher stroke risk than 50-79% stenoses. CONCLUSIONS: Although aggressive risk factor control and BMT should be implemented in all ACS patients, several high-risk features that may increase the risk of a future cerebrovascular event are now documented. Consequently, some guidelines recommend a prophylactic carotid intervention in high-risk patients to prevent future cerebrovascular events. Until the results of the much-anticipated randomized controlled trials emerge, the jury is still out regarding the optimal management of ACS patients.
Authors: Kosmas I Paraskevas; Dimitri P Mikhailidis; Hediyeh Baradaran; Reinoud P H Bokkers; Alun H Davies; Hans-Henning Eckstein; Gianluca Faggioli; Jose Fernandes E Fernandes; Mauro Gargiulo; Arkadiusz Jawien; Mateja K Jezovnik; Stavros K Kakkos; Michael Knoflach; M Eline Kooi; Gaetano Lanza; Christos D Liapis; Ian M Loftus; Armando Mansilha; Laura Mechtouff; Antoine Millon; Piotr Myrcha; Andrew N Nicolaides; Rodolfo Pini; Pavel Poredos; Jean-Baptiste Ricco; Tatjana Rundek; Luca Saba; Mauro Silvestrini; Francesco Spinelli; Francesco Stilo; Sherif Sultan; Jasjit S Suri; Alexei V Svetlikov; Tissa Wijeratne; Clark J Zeebregts; Peter Gloviczki Journal: Ann Transl Med Date: 2022-02
Authors: Kosmas I Paraskevas; Dimitri P Mikhailidis; Hediyeh Baradaran; Alun H Davies; Hans-Henning Eckstein; Gianluca Faggioli; Jose Fernandes E Fernandes; Ajay Gupta; Mateja K Jezovnik; Stavros K Kakkos; Niki Katsiki; M Eline Kooi; Gaetano Lanza; Christos D Liapis; Ian M Loftus; Antoine Millon; Andrew N Nicolaides; Pavel Poredos; Rodolfo Pini; Jean-Baptiste Ricco; Tatjana Rundek; Luca Saba; Francesco Spinelli; Francesco Stilo; Sherif Sultan; Clark J Zeebregts; Seemant Chaturvedi Journal: J Stroke Date: 2022-01-31 Impact factor: 6.967