Comparative Review of the Treatment Methodologies of Carotid Stenosis
Coney Bae1, Mauricio Szuchmacher1, John B Chang1
1Division of Vascular Surgery, Department of Surgery, Hofstra North Shore-Long Island Jewish School of Medicine, New York, New York.
Insights
Carotid stenosis treatment involves medical management, stenting (CAS), and surgery (CEA). While CEA is preferred for severe symptomatic cases, evolving medical therapies may offer better outcomes for asymptomatic patients.
Area of Science:
- Vascular Surgery
- Neurology
- Cardiology
Background:
- Carotid stenosis poses a significant stroke risk.
- Established treatments include medical management, carotid angioplasty and stenting (CAS), and carotid endarterectomy (CEA).
- Clinical trials like NASCET, ECST, ACAS, and ACST have guided treatment decisions.
Purpose of the Study:
- To review and compare current treatment strategies for carotid stenosis.
- To evaluate the efficacy and safety of CAS versus CEA.
- To discuss the evolving role of medical management and future trial directions.
Main Methods:
- Comparative analysis of landmark clinical trials (NASCET, ECST, ACAS, ACST, CREST).
- Review of procedural techniques for CEA (patch vs. primary closure, eversion technique).
- Consideration of patient-specific factors and emerging medical therapies.
Main Results:
- CEA is recommended for symptomatic stenosis >70% and asymptomatic stenosis >60%.
- CREST trial showed similar stroke/death rates for CAS and CEA, but CAS had higher adverse events in women and elderly.
- Patch angioplasty and eversion technique show durable results in CEA.
Conclusions:
- Optimal treatment for carotid stenosis depends on symptom status and degree of stenosis.
- CAS may be suitable for specific cases like restenosis or high-risk patients.
- Advancements in medical management may shift treatment paradigms, particularly for asymptomatic carotid stenosis.
Abstract:
The treatment of carotid stenosis entails three methodologies, namely, medical management, carotid angioplasty and stenting (CAS), as well as carotid endarterectomy (CEA). The North American Symptomatic Carotid Endarterectomy Trial (NASCET) and European Carotid Surgery Trial (ECST) have shown that symptomatic carotid stenosis greater than 70% is best treated with CEA. In asymptomatic patients with carotid stenosis greater than 60%, CEA was more beneficial than treatment with aspirin alone according to the Asymptomatic Carotid Atherosclerosis (ACAS) and Asymptomatic Carotid Stenosis Trial (ACST) trials. When CAS is compared with CEA, the CREST resulted in similar rates of ipsilateral stroke and death rates regardless of symptoms. However, CAS not only increased adverse effects in women, it also amplified stroke rates and death in elderly patients compared with CEA. CAS can maximize its utility in treating focal restenosis after CEA and patients with overwhelming cardiac risk or prior neck irradiation. When performing CEA, using a patch was equated to a more durable result than primary closure, whereas eversion technique is a new methodology deserving a spotlight. Comparing the three major treatment strategies of carotid stenosis has intrinsic drawbacks, as most trials are outdated and they vary in their premises, definitions, and study designs. With the newly codified best medical management including antiplatelet therapies with aspirin and clopidogrel, statin, antihypertensive agents, strict diabetes control, smoking cessation, and life style change, the current trials may demonstrate that asymptomatic carotid stenosis is best treated with best medical therapy. The ongoing trials will illuminate and reshape the treatment paradigm for symptomatic and asymptomatic carotid stenosis.
