The conundrum of asymptomatic carotid stenosis-determinants of decision and evidence
José Fernandes E Fernandes1,2,3, Luis Mendes Pedro3,4,5, Isabel Gonçalves6
1Department of Surgery and Vascular Surgery, Faculty of Medicine University of Lisbon, Lisbon, Portugal.
Insights
Identifying vulnerable carotid lesions is key to preventing strokes. This strategy aims to reduce unnecessary interventions for asymptomatic carotid stenosis, improving patient outcomes.
Area of Science:
- Vascular Surgery
- Neurology
- Public Health
Background:
- Asymptomatic carotid stenosis poses a significant stroke risk, accounting for 11-15% of first neurologic events.
- Current guidelines support intervention, but this leads to many unnecessary procedures.
- Advances in medical management have reduced stroke incidence, challenging established practices.
Purpose of the Study:
- To review the natural history of asymptomatic carotid stenosis.
- To evaluate diagnostic methods for identifying vulnerable plaques.
- To propose a management strategy to reduce unnecessary interventions and prevent strokes.
Main Methods:
- Systematic review of published literature on asymptomatic carotid stenosis.
- Analysis of diagnostic techniques for plaque vulnerability assessment.
- Evaluation of current outcomes for carotid endarterectomy and stenting.
Main Results:
- Conflicting evidence exists regarding the optimal management of asymptomatic carotid stenosis.
- Medical management, including risk factor control, has decreased stroke incidence.
- Identifying vulnerable lesions and high-risk patients is crucial for effective intervention.
Conclusions:
- A refined management strategy for asymptomatic carotid stenosis is needed.
- Focusing on vulnerable lesions and patients can improve intervention effectiveness.
- The proposed strategy aims to minimize unnecessary procedures and enhance stroke prevention.
Abstract:
Management of asymptomatic carotid disease continues to challenge medical practice and present evidence is often conflicting. Stroke is a significant burden in Public Health and 11% to 15% appear as first neurologic event associated with asymptomatic carotid stenosis. Randomized trials provided support for Guidelines and Recommendations to intervene on asymptomatic stenosis, but at a known cost of a high number of unnecessary operations. Conflicting evidence from natural history studies and the widespread use of proper medical management including risk factors control, lowering-lipid drugs and strict control of arterial hypertension have reduced the incidence of strokes associated to asymptomatic carotid disease challenging established practice. Need to identify vulnerable lesions prone to develop thromboembolic brain events and also vulnerable patients at a higher risk of stroke is necessary and essential to further improve effectiveness of our interventions. After review of published literature on natural history of asymptomatic carotid stenosis, diagnostic methods to identify plaque vulnerability and present-day results of both endarterectomy and stenting, a strategy for management of asymptomatic carotid stenosis is suggested aiming to reduce unnecessary interventions and effectively contribute to stroke prevention.
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