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Consensus against both endarterectomy and routine screening for asymptomatic carotid artery stenosis. Canadian Stroke
J R Perry1, J P Szalai, J W Norris
1Division of Neurology, Sunnybrook Health Science Centre, University of Toronto, Ontario.
Insights
Current evidence does not support carotid endarterectomy for asymptomatic patients. Experts also reject screening for asymptomatic carotid stenosis, even in high-risk individuals, due to insufficient evidence of benefit.
Area of Science:
- Neurology
- Vascular Surgery
- Evidence-Based Medicine
Background:
- The efficacy of carotid endarterectomy for asymptomatic patients remains debated despite existing randomized controlled trials.
- There is a need for validated, evidence-based guidelines to inform clinical practice regarding carotid stenosis management.
Purpose of the Study:
- To develop evidence-based guidelines for the management of asymptomatic carotid stenosis.
- To assess expert consensus on the role of carotid endarterectomy and screening strategies.
Main Methods:
- A Delphi consensus process involving 35 experts from the Canadian Stroke Consortium.
- Review of evidence-based guidelines from the Canadian Task Force on the Periodic Health Examination.
- Three rounds of consensus-building to achieve expert agreement.
Main Results:
- High interrater agreement was achieved on all developed guidelines.
- Experts found insufficient evidence to recommend carotid endarterectomy for asymptomatic patients with >60% stenosis (kappa = 0.70).
- Screening for asymptomatic carotid stenosis in the general population or high-risk groups was unanimously rejected (kappa = 0.91 and 0.79).
Conclusions:
- Insufficient evidence exists to support carotid endarterectomy in asymptomatic individuals.
- Screening strategies for asymptomatic carotid stenosis, even in patients with risk factors, are not endorsed due to lack of proven benefit.
- Current recommendations advise against screening or surgical intervention for asymptomatic carotid disease as a stroke prevention method.
Background:
Despite several randomized controlled trials, the role of carotid endarterectomy for asymptomatic patients is controversial. Validated evidence-based guidelines are needed.
Methods:
Thirty-five members of the Canadian Stroke Consortium, an independent body of cerebrovascular disease experts, reviewed evidence-based guidelines developed by the Canadian Task Force on the Periodic Health Examination. We held 3 rounds of Delphi consensus to solicit opinion and agreement.
Results:
We found a high level of interrater agreement for all guidelines using multiple statistical measures. Members agreed that evidence is insufficient to endorse carotid endarterectomy for asymptomatic patients with angiographically proven stenosis of more than 60% (kappa = 0.70, P < .01). Reasons cited included concern over the reproducibility of low surgical morbidity rates in the community at large, the questionable clinical benefit conferred by surgery, and the lack of proven reduction in the risk of major disabling stroke. Screening the general population for asymptomatic stenosis was unanimously rejected. Also, screening even patients with risk factors or proven atherosclerosis at other sites was not endorsed (kappa = 0.91 and kappa = 0.79, respectively, both P < .01).
Conclusions:
There is insufficient evidence to recommend carotid endarterectomy for asymptomatic patients. Evidence is also insufficient to endorse a screening strategy even for patients with risk factors for carotid disease. While stroke prevention remains a critical goal, we do not recommend that it be accomplished by screening or by performing carotid surgery in asymptomatic patients.