Carotid Artery Disease: Then and Now

 Did your competent? doctor tell you about the risks of either? My definition of competent is a doctor that knows more than me.

For me, with no medical background the best solution is to determine if the Circle of Willis is complete, then close up the offending artery. Don't listen to me.

Low Stroke Risk in Patients With Asymptomatic Severe Carotid Stenosis

 

You might want to ask your doctor about this?

New ischemic brain lesions on diffusion-weighted MRI after treatment were found in 51% of cases after stenting.  Link here

You might want to prevent stent placement complications per European Society of Cardiology

A - Minor complications

• Carotid artery spasm

• Sustained hypotension / bradycardia

• Carotid artery dissection

• Contrast encephalopathy (very rare)

• Minor embolic neurological events (TIAs)

B - Major complications

• Major embolic stroke

• Intracranial hemorrhage

• Hyperperfusion syndrome

• Carotid perforation (very rare)

• Acute stent thrombosis (very rare)

• Complications at the site of the vascular access

Carotid Artery Disease: Then and Now 

Thomas G. Brott,

Gary S. Roubin,

Wesley S. Moore and

James F. Meschia

Originally published5 Mar 2024https://doi.org/10.1161/SVIN.123.001076Stroke: Vascular and Interventional Neurology. 2024;4:e001076

Interventions for carotid revascularization have been pioneered over the past 70 years, and safety for those interventions has been achieved (Figure  ). Concurrently, drugs to prevent and treat atherosclerosis have been invented with improving safety, tolerability, and efficacy. The plummeting use of cigarettes and other cultural changes have complemented interventional and medical treatments, culminating in a decreasing burden from carotid disease and stroke. This overview focuses on those medical and interventional treatments. Optimal management for patients with high‐grade asymptomatic carotid stenosis remains to be defined.

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Figure  .  

Medical Treatments

The safety and efficacy of medical treatment without revascularization have not been tested this century in a randomized clinical trial (RCT) focused on patients with high‐grade carotid stenosis. Only 113 patients were in the medical group in the SPACE‐2 (Stent‐Supported Percutaneous Angioplasty of the Carotid Artery Versus Endarterectomy‐2) trial.¹ The most recent comprehensive guideline statement recommends low‐dose aspirin, antihypertensive treatment for patients with hypertension, lipid‐lowering therapy with statins, ezetimibe, and PCSK‐9 (proprotein convertase subtilisin/kexin type 9) inhibitors, as needed, and optimal glycemic control of diabetes.² Behavioral counseling to assist patients in achieving a healthy lifestyle is also recommended. In CREST‐2 (Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial),³ intensive medical treatment (IMT) is the experimental arm because carotid endarterectomy (CEA) and carotid artery stenting (CAS) have been compared with each other in preceding carotid RCTs. The CREST‐2 IMT protocol includes guideline medical treatment recommendations, behavioral counseling, and the option for PCSK‐9 inhibitors.³ The systolic blood pressure goal is <130 mm Hg, and the goal for lipid control is low‐density lipoprotein <70 mg/dL. The medical groups in CREST‐2 now have >1000 patients. Accordingly, testing of safety and efficacy of IMT for patients with high‐grade asymptomatic carotid stenosis will be feasible.

Carotid Artery Endarterectomy

CEA to prevent stroke in patients with high‐grade carotid stenosis was pioneered in the early 1950s. The first RCT reported in 1970 was inconclusive.⁴ Larger US and international RCTs followed in the 1990s. These trials provided definitive support for CEA in preventing stroke compared with medical treatment alone.⁴

For symptomatic patients, the North American Symptomatic Carotid Endarterectomy Trial showed an annual absolute risk reduction in ipsilateral stroke of 11.3% for CEA in patients with ≥70% stenosis and an annual absolute risk reduction of 1.3% for patients with 50% to 69% stenosis.⁴ The ECST (European Carotid Surgery Trial) also showed efficacy for CEA.⁴ However, a benefit for CEA was not shown for patients with 50% to 69% stenosis.⁴

For asymptomatic patients, the RCTs of the 1990s consistently favored CEA in preventing ipsilateral stroke.⁴ None of the asymptomatic RCTs showed a relationship of risk or benefit to the degree of carotid stenosis.⁴ Results of these trials for symptomatic and asymptomatic patients form the basis for treatment guidelines and medical practice today. Appropriately powered contemporary RCTs have not been reported.