Transatlantic Differences in Management of Carotid Stenosis: BRIDGing the Gap in StrokE Management (BRIDGE) Project

You can't even discuss the options if your doctor doesn't identify it as a problem. My doctors never found the 80% blockage in my right carotid artery even though they told me that artery had dissected and thrown a clot into my brain. Not sure what orifice they pulled that knowledge out of. 

Transatlantic Differences in Management of Carotid Stenosis: BRIDGing the Gap in StrokE Management (BRIDGE) Project

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Clotilde Balucani, MD, PhD¹

Clotilde Balucani

1The Department of Neurology and Stroke Center, Downstate Medical Center, The State University of New York, SUNY, Brooklyn, New York, NY, USA
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, Vanessa Arnedo, MPH¹

Vanessa Arnedo

1The Department of Neurology and Stroke Center, Downstate Medical Center, The State University of New York, SUNY, Brooklyn, New York, NY, USA
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, Jeremy Weedon, PhD²

Jeremy Weedon

2The Department of Public Health, SUNY Downstate Medical Center, Brooklyn, New York, NY, USA
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Didier Leys, MD³

Didier Leys

3The Department of Neurology, Lille University Hospital, Lille, France
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, Jean-Louis Mas, MD⁴

Jean-Louis Mas

4Neurology Department and Stroke Unit, INSERM UMR S 894, Sainte-Anne Hospital, Paris Descartes University, Paris, France
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, Martin Brown, MD⁵

Martin Brown

5 The Stroke Research Group, UCL Institute of Neurology, London, UK
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, James C. Grotta, MD⁶

James C. Grotta

6Stroke Research, Memorial Hermann Hospital, Houston, TX, USA
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, Nicole R. Gonzales, MD⁷

Nicole R. Gonzales

7The Department of Neurology, UTHealth Medical School, Houston, TX, USA
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, Werner Hacke, MD⁸

Werner Hacke

8The Department of Neurology, Heidelberg, Germany
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, Thomas Brott, MD⁹

Thomas Brott

9The Department of Neurology, The Mayo Clinic, Jacksonville, FL, USA
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, Steven R. Levine, MD¹

Steven R. Levine

1The Department of Neurology and Stroke Center, Downstate Medical Center, The State University of New York, SUNY, Brooklyn, New York, NY, USA
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First Published January 17, 2018 Research Article

https://doi.org/10.1177/1941874417747772

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Article Information

Article first published online: January 17, 2018

https://doi.org/10.1177/1941874417747772

Clotilde Balucani, MD, PhD¹, Vanessa Arnedo, MPH¹, Jeremy Weedon, PhD², Didier Leys, MD³, Jean-Louis Mas, MD⁴, Martin Brown, MD⁵, James C. Grotta, MD⁶, Nicole R. Gonzales, MD⁷, Werner Hacke, MD⁸, Thomas Brott, MD⁹, Steven R. Levine, MD¹

¹The Department of Neurology and Stroke Center, Downstate Medical Center, The State University of New York, SUNY, Brooklyn, New York, NY, USA

²The Department of Public Health, SUNY Downstate Medical Center, Brooklyn, New York, NY, USA

³The Department of Neurology, Lille University Hospital, Lille, France

⁴Neurology Department and Stroke Unit, INSERM UMR S 894, Sainte-Anne Hospital, Paris Descartes University, Paris, France

⁵ The Stroke Research Group, UCL Institute of Neurology, London, UK

⁶Stroke Research, Memorial Hermann Hospital, Houston, TX, USA

⁷The Department of Neurology, UTHealth Medical School, Houston, TX, USA

⁸The Department of Neurology, Heidelberg, Germany

⁹The Department of Neurology, The Mayo Clinic, Jacksonville, FL, USA

Corresponding Author: Clotilde Balucani, Department of Neurology and Stroke Center, SUNY Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, New York, NY 11203, USA. Email: clotilde.balucani@downstate.edu

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Abstract

Background and Purpose:

Management of carotid stenosis remains controversial despite several trials evaluating carotid endarterectomy (CEA) and carotid angioplasty/stenting (CAS). We compared attitudes in the management of carotid stenosis between selected experts within Europe and North America.

Methods:

A 3-phase Delphi survey was e-mailed to select stroke experts from Europe (n = 390) and North America (n = 289). Those completing the initial survey were shown all responses after each survey round. Consensus was defined as ≥80% agreement.

Results:

For phases 1, 2, and 3, response rates were 32%, 62%, and 73%, respectively. Overall, 100 (15%) of 679 participated in all 3 phases, 19% Europeans versus 9% North Americans (P = .0007). The European group reached consensus in 6 of 15 statements; The North American group reached consensus in 4 of 15. Ninety percentage of Europeans versus 70% of North Americans (P = .017) stated CEA is superior to CAS for symptomatic carotid stenosis. This difference was not significant in the final model (adjusted odds ratio: 3.72 [95% confidence interval: 0.95-14.5]). Sixty-nine percentage of North Americans agreed there is a stronger indication for CAS over CEA in patients younger than 65 years for symptomatic carotid stenosis, whereas 55% of Europeans (P = .023) disagreed. For asymptomatic carotid stenosis, when asked how likely they would recommend CAS, 62% North Americans said “sometimes” versus 60% of Europeans said “never” (P = .06).

Conclusion:

The majority of North American and European respondents did not consider the 2 procedures equivalent and seemed to indicate that CEA was preferred for the management of carotid stenosis. These findings need to be further explored to help establish evidence-based guidelines.