Medical Management of Patients With Symptomatic Carotid Artery Stenosis
Eric T A Lim1, Geoffrey Ying2, Oliver Bernau1
1Department of Vascular Surgery, Waikato Hospital, Hamilton, New Zealand.
Insights
For symptomatic carotid artery stenosis, medical management shows stroke-free survival comparable to surgery. However, patients undergoing carotid intervention had better overall survival rates in this study.
Area of Science:
- Vascular Surgery
- Neurology
- Cardiovascular Medicine
Background:
- Carotid endarterectomy (CEA) is recommended for symptomatic >50% internal carotid artery stenosis.
- Limited contemporary data exists on the natural history of medically managed symptomatic carotid artery stenosis.
- This study aimed to evaluate outcomes for patients with symptomatic carotid artery stenosis managed non-surgically.
Purpose of the Study:
- To assess the outcomes of patients with symptomatic carotid artery stenosis managed with medical therapy alone.
- To compare stroke-free survival and all-cause mortality between medically and surgically managed patients.
Main Methods:
- Prospective observational study conducted at a tertiary vascular referral center (June 2019 - January 2024).
- Surgical intervention threshold set at ≥70-99% stenosis for symptomatic internal carotid artery.
- Primary outcomes: stroke-free survival and all-cause mortality, analyzed using Kaplan-Meier methods.
Main Results:
- Out of 280 patients, 29.2% (63) were managed medically; 69.4% (150) underwent CEA.
- Medically managed patients experienced a 4.8% rate of further ipsilateral ischemic stroke.
- At 4 years, stroke-free survival was 88% for medical management vs. 88% for surgical intervention; overall survival was 57% vs. 88% respectively.
Conclusions:
- While carotid intervention improved survival, the risk of future ipsilateral stroke appears similar between medically and surgically managed patients.
- Further large-scale studies are necessary to definitively compare long-term outcomes of carotid surgery versus medical management for symptomatic carotid artery stenosis.
Background:
Level 1 evidence recommends that carotid endarterectomy (CEA) should be considered for symptomatic >50% internal carotid artery stenosis for stroke prevention. However, there is little contemporary data on the natural history of patients with symptomatic carotid artery stenosis who were managed with medical therapy alone. The aim of this study was to assess the outcomes of patients with symptomatic carotid artery stenosis who were managed medically.
Methods:
This was a prospective observational study at a tertiary vascular referral center. The study period was from June 1, 2019, to January 1, 2024. Threshold for surgical intervention in patients with a symptomatic internal carotid artery was set at a stenosis of ≥70-99% as defined by societal guidelines. The primary outcome was stroke-free survival and all-cause mortality. Kaplan-Meier analysis was performed to assess stroke-free survival and all-cause mortality.
Results:
There were 280 patients who were referred for management of symptomatic carotid artery stenosis during the study period. One-hundred fifty patients (69.4%) were treated with a CEA, 3 patients (1.4%) with carotid artery stenting, and the remaining 63 patients (29.2%) were managed medically. Of the patients managed medically, three patients (4.8%) developed a further ipsilateral ischemic stroke during the follow-up period. Any stroke-free survival for medically versus surgically managed patients at 1 and 4 years were both 94% vs. 94% and 88%, respectively. Overall, the medically managed patient group survival compared with those who had carotid intervention at 1 and 4 years were 88% and 57% vs. 97% and 88%, respectively.
Conclusion:
Patients who underwent intervention for symptomatic carotid disease have better survival; however, risk of future ipsilateral stroke events appear to be comparable with patients who had medical management only. Larger studies are warranted to confirm the long-term outcomes between carotid surgery and medical management in symptomatic carotid artery stenosis.
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