Identifying the high-risk carotid plaque
1Vascular Surgery Group Division of Cardiovascular Sciences Leicester Royal Infirmary, Leicester, UK - ross.naylor@uhl-tr.nhs.uk.
Insights
Most patients treated for carotid artery disease do not benefit from surgery or stenting. Identifying high-risk stroke plaques using imaging and biomarkers is crucial for targeted, effective interventions.
Area of Science:
- Neurology
- Vascular Surgery
- Biomarkers
Background:
- Randomized trials indicate most symptomatic and asymptomatic patients receiving medical treatment were unlikely to experience a stroke.
- A significant proportion of carotid interventions, including surgery and stenting, are deemed unnecessary even with zero procedural risk.
Purpose of the Study:
- To review the rationale for identifying patients with high-risk carotid plaques who would benefit from invasive therapies.
- To explore the use of contemporary imaging and serum biomarkers for detecting unstable carotid plaques.
Main Methods:
- Review of existing literature on carotid artery disease management and stroke risk stratification.
- Discussion of pathophysiological mechanisms of unstable carotid plaques.
- Evaluation of current imaging modalities and serum biomarkers for plaque assessment.
Main Results:
- The majority of patients undergoing medical treatment in trials did not progress to stroke.
- A substantial percentage of carotid surgical procedures, particularly for asymptomatic disease, are unnecessary.
- Current methods often fail to accurately select patients who will benefit from interventions.
Conclusions:
- There is a critical need to identify patients with high-risk carotid plaques to optimize the use of invasive therapies.
- Contemporary imaging and serum biomarkers hold promise for identifying unstable plaques and guiding treatment decisions.
- Targeting interventions based on plaque risk stratification could improve patient outcomes and reduce unnecessary procedures.
Abstract:
With the benefit of hindsight, most symptomatic (67%) and most asymptomatic patients (88%) who were treated medically in the randomized trials were never destined to suffer a stroke. As a consequence of a growing awareness that only a relative minority of patients actually benefit from surgery or stenting, there has been much debate about how contemporary imaging and serum biomarkers might be used to identify the patient with the "high-risk for stroke" plaque in whom to target surgery or stenting in the future. This is particularly important for patients with asymptomatic carotid disease in whom 95% of carotid surgical procedures are ultimately unnecessary. Even if the procedural risk could be reduced to zero, 93% of all interventions would still prove to be unnecessary. This paper reviews the rationale underlying the need to identify "high-risk for stroke" patients in whom to target invasive therapies. It reviews the pathophysiology of the unstable carotid plaque and how such a lesion might be identified using contemporary imaging modalities and serum biomarkers.
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