Optimal Management of Asymptomatic Carotid Stenosis in 2021: The Jury is Still Out. An International, Multispecialty, Expert Review and Position Statement

Paraskevas K. I.;Mikhailidis D. P.;Antignani P. L.;Baradaran H.;Bokkers R. P. H.;Cambria R. P.;Dardik A.;Davies A. H.;Eckstein H. -H.;Faggioli G.;e Fernandes J. F.;Fraedrich G.;Geroulakos G.;Gloviczki P.;Golledge J.;Gupta A.;Jezovnik M. K.;Kakkos S. K.;Katsiki N.;Knoflach M.;Kooi M. E.;Lanza G.;Liapis C. D.;Loftus I. M.;Mansilha A.;Millon A.;Nicolaides A. N.;Pini R.;Poredos P.;Ricco J. -B.;Riles T. S.;Ringleb P. A.;Rundek T.;Saba L.;Schlachetzki F.;Silvestrini M.;Spinelli F.;Stilo F.;Sultan S.;Suri J. S.;Zeebregts C. J.;Chaturvedi S.

2022-01-01

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Abstract

Objectives: The recommendations of international guidelines for the management of asymptomatic carotid stenosis (ACS) often vary considerably and extend from a conservative approach with risk factor modification and best medical treatment (BMT) alone, to a more aggressive approach with a carotid intervention plus BMT. The aim of the current multispecialty position statement is to reconcile the conflicting views on the topic. Materials and methods: A literature review was performed with a focus on data from recent studies. Results: Several clinical and imaging high-risk features have been identified that are associated with an increased long-term ipsilateral ischemic stroke risk in patients with ACS. Such high-risk clinical/imaging features include intraplaque hemorrhage, impaired cerebrovascular reserve, carotid plaque echolucency/ulceration/ neovascularization, a lipid-rich necrotic core, a thin or ruptured fibrous cap, silent brain infarction, a contralateral transient ischemic attack/stroke episode, male patients < 75 years and microembolic signals on transcranial Doppler. There is growing evidence that 80–99% ACS indicate a higher stroke risk than 50–79% stenoses. Conclusions: Although aggressive risk factor control and BMT should be implemented in all ACS patients, several high-risk features that may increase the risk of a future cerebrovascular event are now documented. Consequently, some guidelines recommend a prophylactic carotid intervention in high-risk patients to prevent future cerebrovascular events. Until the results of the much-anticipated randomized controlled trials emerge, the jury is still out regarding the optimal management of ACS patients.