Systematic Review of Guidelines for the Management of Asymptomatic and Symptomatic Carotid Stenosis
Anne L Abbott1, Kosmas I Paraskevas2, Stavros K Kakkos2
1From the Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine (A.L.A, M.D.), Department of Surgery, Central Clinical School (M.B.), Monash University, Melbourne, Victoria, Australia; Neurology Department, The Alfred Hospital, Prahran, Victoria, Australia (A.L.A.); Department of Cardiovascular Sciences, St. George'sVascular Institute, St George's Hospital, London, United Kingdom (K.I.P.); Department of Vascular Surgery, University of Patras, Patras, Greece (S.K.K.); Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia (J.G.); Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, Queensland, Australia (J.G.); Department for Vascular and Endovascular Surgery, Klinikum Rechts der Isar, Technical University Munich, Munich, Germany (H.-H.E.); Department of Medicine, Michigan State University, Metro Health Hospital, Grand Rapids, MI (L.J.D.-S.); Cardiology Department, Xiamen Cardiovascular Hospital, Xiamen, Fujian, China (L.C.); Center for Cardiology Intervention Treatment, Department of Cardiology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China (Q.F.); Stroke Unit, Department of Neurology, Western Hospital, University of Melbourne, Footscray, Melbourne, Victoria, Australia (T.W.); Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China (T.W.L.); Department of Vascular Surgery, University of Arizona and Pima Vascular Group, Tucson (M.M.-B.); Department of Neurology, Hallym Neurological Institute, Hallym University, Sacred Heart Hospital, Seoul, South Korea (B.-C.L.); Centre for Health and Social Research, Faculty of Health Sciences, Australian Catholic University, Melbourne, Victoria, Australia (S.P.); and Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany (P.R.). Anne.L.Abbott@gmail.com.
Insights
Contemporary guidelines for carotid artery stenosis management need modernization. Current recommendations for carotid endarterectomy (CEA) and carotid angioplasty/stenting (CAS) often rely on outdated evidence and lack standardized terminology.
Area of Science:
- Vascular Surgery
- Clinical Guidelines
- Evidence-Based Medicine
Background:
- Contemporary guidelines for managing carotid artery stenosis (CAS) vary significantly.
- A systematic appraisal of these guidelines is crucial for improving patient care.
Purpose of the Study:
- To systematically compare and appraise current guidelines on the management of asymptomatic and symptomatic carotid artery stenosis.
- To identify opportunities for modernizing guideline recommendations.
Main Methods:
- Systematic search for guidelines on carotid endarterectomy (CEA) or carotid angioplasty/stenting (CAS) published between 2008 and 2015.
- Independent analysis of selected guidelines by multiple authors to assess recommendations, clinical scenarios, and evidence base.
Main Results:
- 34 guidelines were analyzed, with varying recommendations for CEA and CAS in both asymptomatic and symptomatic patients.
- Many guidelines relied on data from trials over a decade old, rarely incorporating medical treatment advances or potential CAS risks.
- Inconsistent terminology hindered guideline interpretation and comparison.
Conclusions:
- Significant opportunities exist to update and enhance carotid stenosis management guidelines.
- Modernization should incorporate recent evidence and standardize terminology for clarity.
Background And Purpose:
We systematically compared and appraised contemporary guidelines on management of asymptomatic and symptomatic carotid artery stenosis.
Methods:
We systematically searched for guideline recommendations on carotid endarterectomy (CEA) or carotid angioplasty/stenting (CAS) published in any language between January 1, 2008, and January 28, 2015. Only the latest guideline per writing group was selected. Each guideline was analyzed independently by 2 to 6 authors to determine clinical scenarios covered, recommendations given, and scientific evidence used.
Results:
Thirty-four eligible guidelines were identified from 23 different regions/countries in 6 languages. Of 28 guidelines with asymptomatic carotid artery stenosis procedural recommendations, 24 (86%) endorsed CEA (recommended it should or may be provided) for ≈50% to 99% average-surgical-risk asymptomatic carotid artery stenosis, 17 (61%) endorsed CAS, 8 (29%) opposed CAS, and 1 (4%) endorsed medical treatment alone. For asymptomatic carotid artery stenosis patients considered high-CEA-risk because of comorbidities, vascular anatomy, or undefined reasons, CAS was endorsed in 13 guidelines (46%). Thirty-one of 33 guidelines (94%) with symptomatic carotid artery stenosis procedural recommendations endorsed CEA for patients with ≈50% to 99% average-CEA-risk symptomatic carotid artery stenosis, 19 (58%) endorsed CAS and 9 (27%) opposed CAS. For high-CEA-risk symptomatic carotid artery stenosis because of comorbidities, vascular anatomy, or undefined reasons, CAS was endorsed in 27 guidelines (82%). Guideline procedural recommendations were based only on results of trials in which patients were randomized 12 to 34 years ago, rarely reflected medical treatment improvements and often understated potential CAS hazards. Qualifying terminology summarizing recommendations or evidence lacked standardization, impeding guideline interpretation, and comparison.
Conclusions:
This systematic review has identified many opportunities to modernize and otherwise improve carotid stenosis management guidelines.
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