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Carotid Endarterectomy Following Intravenous Thrombolysis in the UK.

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50 Shades of 'Groundhog Day'.

A Ross Naylor1

  • 1The Leicester Vascular Institute, Glenfield Hospital, Leicester, UK.

EJVES Vascular Forum
|September 23, 2022
PubMed
Summary

New data show asymptomatic carotid stenosis (ACS) is linked to cognitive impairment, but carotid endarterectomy (CEA) or stenting (CAS) do not prevent dementia. The 2023 European Society for Vascular Surgery guidelines maintain their stance against these procedures for cognitive protection.

Area of Science:

  • Vascular Surgery
  • Neurology
  • Cognitive Science

Background:

  • The 2017 European Society for Vascular Surgery (ESVS) guidelines found insufficient evidence for carotid endarterectomy (CEA) or carotid artery stenting (CAS) in asymptomatic carotid stenosis (ACS) to prevent cognitive decline.
  • Recent studies investigate the association between ACS and cognitive impairment, exploring potential benefits of revascularization procedures.

Purpose of the Study:

  • To review new data on asymptomatic carotid stenosis (ACS) and cognitive function since 2017.
  • To determine if emerging evidence has influenced the 2023 ESVS guidelines regarding CEA and CAS for cognitive protection.

Main Methods:

  • Systematic review of studies assessing the association between ACS and cognitive impairment.
  • Analysis of baseline data from the CREST-2 trial on cognitive scores in ACS patients.
Keywords:
Asymptomatic carotid diseaseCognitive functionDementia

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  • Review of long-term outcomes from the ACST-1 trial comparing CEA to best medical therapy (BMT).

    • Main Results:

    • A high percentage of studies (94%) report a significant association between ACS and cognitive impairment.
    • Patients with ACS exhibit lower cognitive Z scores, particularly in memory recall and learning.
    • Long-term follow-up shows no significant difference in dementia rates between CEA and BMT (ACST-1), and mixed results on cognitive function changes after CEA/CAS.

    Conclusions:

    • While ACS is associated with cognitive impairment, its direct causal role remains unclear.
    • Current evidence does not support the use of CEA or CAS to prevent late-onset dementia in ACS patients.
    • The 2023 ESVS guidelines reaffirm the 2017 recommendations, not supporting revascularization for cognitive protection.