Updated Society for Vascular Surgery guidelines for management of extracranial carotid disease
2011; Elsevier BV; Volume: 54; Issue: 3 Linguagem: Inglês
10.1016/j.jvs.2011.07.031
ISSN1097-6809
AutoresJohn J. Ricotta, Ali F. AbuRahma, Enrico Ascher, Mark K. Eskandari, Peter L. Faries, Brajesh K. Lal,
Tópico(s)Cardiovascular Health and Disease Prevention
ResumoManagement of carotid bifurcation stenosis is a cornerstone of stroke prevention and has been the subject of extensive clinical investigation, including multiple controlled randomized trials. The appropriate treatment of patients with carotid bifurcation disease is of major interest to the community of vascular surgeons. In 2008, the Society for Vascular Surgery published guidelines for treatment of carotid artery disease. At the time, only one randomized trial, comparing carotid endarterectomy (CEA) and carotid stenting (CAS), had been published. Since that publication, four major randomized trials comparing CEA and CAS have been published, and the role of medical management has been re-emphasized. The current publication updates and expands the 2008 guidelines with specific emphasis on six areas: imaging in identification and characterization of carotid stenosis, medical therapy (as stand-alone management and also in conjunction with intervention in patients with carotid bifurcation stenosis), risk stratification to select patients for appropriate interventional management (CEA or CAS), technical standards for performing CEA and CAS, the relative roles of CEA and CAS, and management of unusual conditions associated with extracranial carotid pathology. Recommendations are made using the GRADE (Grades of Recommendation Assessment, Development and Evaluation) system, as has been done with other Society for Vascular Surgery guideline documents. The committee recommends CEA as the first-line treatment for most symptomatic patients with stenosis of 50% to 99% and asymptomatic patients with stenosis of 60% to 99%. The perioperative risk of stroke and death in asymptomatic patients must be <3% to ensure benefit for the patient. CAS should be reserved for symptomatic patients with stenosis of 50% to 99% at high risk for CEA for anatomic or medical reasons. CAS is not recommended for asymptomatic patients at this time. Asymptomatic patients at high risk for intervention or with <3 years life expectancy should be considered for medical management as the first-line therapy. Management of carotid bifurcation stenosis is a cornerstone of stroke prevention and has been the subject of extensive clinical investigation, including multiple controlled randomized trials. The appropriate treatment of patients with carotid bifurcation disease is of major interest to the community of vascular surgeons. In 2008, the Society for Vascular Surgery published guidelines for treatment of carotid artery disease. At the time, only one randomized trial, comparing carotid endarterectomy (CEA) and carotid stenting (CAS), had been published. Since that publication, four major randomized trials comparing CEA and CAS have been published, and the role of medical management has been re-emphasized. The current publication updates and expands the 2008 guidelines with specific emphasis on six areas: imaging in identification and characterization of carotid stenosis, medical therapy (as stand-alone management and also in conjunction with intervention in patients with carotid bifurcation stenosis), risk stratification to select patients for appropriate interventional management (CEA or CAS), technical standards for performing CEA and CAS, the relative roles of CEA and CAS, and management of unusual conditions associated with extracranial carotid pathology. Recommendations are made using the GRADE (Grades of Recommendation Assessment, Development and Evaluation) system, as has been done with other Society for Vascular Surgery guideline documents. The committee recommends CEA as the first-line treatment for most symptomatic patients with stenosis of 50% to 99% and asymptomatic patients with stenosis of 60% to 99%. The perioperative risk of stroke and death in asymptomatic patients must be <3% to ensure benefit for the patient. CAS should be reserved for symptomatic patients with stenosis of 50% to 99% at high risk for CEA for anatomic or medical reasons. CAS is not recommended for asymptomatic patients at this time. Asymptomatic patients at high risk for intervention or with <3 years life expectancy should be considered for medical management as the first-line therapy. IIndications for carotid bifurcation imaging AIndications for imaging the neurologically symptomatic patientBIndications for imaging the neurologically asymptomatic patient 1Screening for asymptomatic carotid stenosis aScreening patients with asymptomatic bruitbPotential “high-risk groups” who might benefit from screening for asymptomatic stenosis•Recommendations for the use of carotid bifurcation imagingIISelecting imaging modalities for carotid evaluation ACarotid duplex ultrasound imagingBMagnetic resonance imaging and angiographyCComputed tomography angiographyDCatheter-based digital subtraction arteriographyEComparison of CDUS, MRA, CTA, and DSA•Recommendations for selection of carotid imaging modalitiesIIIMedical management of patients with carotid stenosis ATreatment of hypertensionBTreatment of diabetes mellitusCTreatment of lipid abnormalitiesDSmoking cessationEAntithrombotic treatmentFAnticoagulant therapyGMedical management for the perioperative period of CEAHMedical management for the perioperative period of CAS•Recommendations for medical management of patients with carotid atherosclerosisIVTechnical recommendations for carotid interventions ACarotid endarterectomyBCarotid artery stenting•Recommendations regarding CEA and CAS techniqueVSelecting the appropriate therapy: medical management, CAS, or CEA AAssessing the risk associated with intervention 1Anatomic and lesion characteristics aLesion locationbLesion characteristicscOther anatomic considerations2Patient characteristicsBNeurologically asymptomatic patients with ≥60% carotid artery stenosis 1CEA for asymptomatic lesions2CAS in asymptomatic lesions3Medical management of asymptomatic carotid stenosisCNeurologically symptomatic patients with ≥50% carotid artery disease 1CEA in symptomatic stenosis2CAS in symptomatic stenosisDMeta-analysis: CEA vs CAS•Recommendations for selecting therapyVIUnusual conditions associated with carotid stenosis AAcute neurologic syndromes 1Management of acute stroke aPresentation within 0-6 hoursbPresentation later than 6 hours2Stroke in evolution (fluctuating neurologic deficits)3Crescendo TIA4Acute postintervention stroke/occlusion•Recommendations for management of acute neurologic syndromesBICA occlusion with persistent symptoms/external carotid stenosis•Recommendations for management of symptomatic ICA occlusionCCarotid dissection•Recommendations for management of carotid dissectionDCombined carotid and coronary disease•Recommendations for management of combined carotid and coronary disease Management of extracranial carotid disease has been the focus of intense investigation and debate by multiple medical specialists since the introduction of carotid endarterectomy (CEA) as a therapeutic option for the treatment and prevention of stroke more than half a century ago. Initial hopes that CEA could reverse the clinical course of stroke were proven false, and the role of surgical management of extracranial carotid and vertebral obstructions was defined by one of the earliest efforts at a multicentered randomized clinical trial, The Joint Study on The Extracranial Circulation.1Fields W.S. North R.R. Hass W.K. Kircheff I.I. Chase N.E. Bauer R.B. et al.Joint study of extracranial arterial occlusion as a cause of Stroke I. Organization of study and survey of patient population.JAMA. 1968; 203: 955-960Crossref PubMed Google Scholar The results of this decade-long study, involving 5000 patients, established the role of CEA in the treatment of minor stroke, transient ischemic attack (TIA), and amaurosis fugax, confirmed that surgery had a limited role in the treatment of established stroke, and established the limited role of vertebral reconstruction in the treatment of cerebral insufficiency. Over the ensuing decades, surgical results of CEA improved, asymptomatic carotid stenosis was increasingly identified by noninvasive studies, and CEA assumed a primarily prophylactic role as prevention of major stroke in asymptomatic patients or those with evidence of transient cerebral or ocular ischemia. Large randomized trials2North American Symptomatic Carotid Endarterectomy Trial Collaborators (NASCET)Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators.N Engl J Med. 1991; 325: 445Crossref PubMed Google Scholar, 3Barnett H.J. Taylor D.W. Eliasziw M. Fox A.J. Ferguson G.G. Haynes R.B. et al.Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators.N Engl J Med. 1998; 339: 1415-1425Crossref PubMed Scopus (1782) Google Scholar, 4Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST).Lancet. 1998; 351: 1379-1387Abstract Full Text Full Text PDF PubMed Scopus (1801) Google Scholar, 5Endarterectomy for asymptomatic carotid artery stenosis. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study.JAMA. 1995; 273: 1421-1428Crossref PubMed Scopus (0) Google Scholar, 6Halliday A. Mansfield A. Marro J. Peto C. Peto R. Potter J. et al.Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomised controlled trial.Lancet. 2004; 363: 1491-1502Abstract Full Text Full Text PDF PubMed Scopus (1148) Google Scholar have established the role and efficacy of carotid endarterectomy (CEA) in stroke prevention. In the last decade, carotid artery stenting (CAS) has emerged as a catheter-based alternative to CEA, and medical therapy for stroke treatment and prevention has evolved. Currently, approximately 135,000 interventions on lesions in the carotid bifurcation are being performed annually in the United States, by a variety of specialists, including vascular surgeons, general surgeons, thoracic surgeons, neurosurgeons, cardiologists, interventional radiologists, and interventional neurologists.7Eslami M.H. McPhee J.T. Simons J.P. Schanzer A. Messina L.M. National trends in utilization and postprocedure outcomes for carotid revascularization 2005 to 2007.J Vasc Surg. 2011; 53: 307-315Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar, 8Cowan J.A. Dimick J.B. Thompson B.C. Stanley J.A. Upchurch G.R. Surgeon volume as an indicator of outcomes after carotid endarterectomy: an effect independent of specialty practice and hospital volume.JACS. 2002; 195: 814-821Google Scholar Approximately 11% of these interventions are catheter-based, and 90% of interventions are in patients without neurologic symptoms.7Eslami M.H. McPhee J.T. Simons J.P. Schanzer A. Messina L.M. National trends in utilization and postprocedure outcomes for carotid revascularization 2005 to 2007.J Vasc Surg. 2011; 53: 307-315Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar As in any situation where there are multiple options for the treatment of a single condition, defining optimal treatment can be difficult. This is further compounded when multiple specialists, often with nonoverlapping expertise, are involved in the treatment of the patient. As a result, a voluminous and often conflicting literature has developed around the current standards of diagnosis and management of extracranial carotid stenosis. Recently two large, prospective, randomized trials have been published comparing the efficacy of CEA and CAS in the management of extracranial carotid stenosis.9Brott T.G. Hobson 2nd, R.W. Howard G. Roubin G.S. Clark W.M. Brooks W. et al.Stenting versus endarterectomy for treatment of carotid-artery stenosis.N Engl J Med. 2010; 363: 11-23Crossref PubMed Scopus (638) Google Scholar, 10Ederle J. Dobson J. Featherstone R.L. Bonati L.H. van der Worp H.B. et al.International Carotid Stenting Study investigatorsCarotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): an interim analysis of a randomised controlled trial.Lancet. 2010; 375: 985-997Abstract Full Text Full Text PDF PubMed Scopus (396) Google Scholar A meta-analysis comparing CAS and CEA, including these trials has recently been published in the Journal of Vascular Surgery.11Murad M.H. Shahrour A. Shah N.D. Montori V.M. Ricotta J.J. A systematic review and meta-analysis of randomized trials of carotid endarterectomy vs stenting.J Vasc Surg. 2011; 53: 792-797Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar In 2008, the Society for Vascular Surgery published clinical practice guidelines for the management of extracranial carotid artery disease in the Journal of Vascular Surgery.12Hobson 2nd, R.W. Mackey W.C. Ascher E. Murad M.H. Calligaro K.D. Comerota A.J. et al.Management of atherosclerotic carotid artery disease: clinical practice guidelines of the Society for Vascular Surgery.J Vasc Surg. 2008; 48: 480-486Abstract Full Text Full Text PDF PubMed Scopus (102) Google Scholar More recently, a multispecialty document has been published on the “Management of Patients with Extracranial Carotid and Vertebral Artery Disease.”13Brott T.G. Halperin J.L. Abbara S. Bacharach J.M. Barr J.D. Bush R.L. et al.2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery Developed in Collaboration With the American Academy of Neurology and Society of Cardiovascular Computed Tomography.J Am Coll Cardiol. 2011; 57: e16-e94Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar This extensive document represents an effort to evaluate the existing literature on extracranial carotid and vertebral disease and is an important reference. The data contained in the recently published randomized trials has prompted the Society for Vascular Surgery to publish an update of its 2008 guidelines, confined to management of extracranial carotid artery disease. This is particularly appropriate because vascular surgeons play a major if not predominant role in the management of patients with carotid bifurcation disease. In developing these recommendations, the committee placed more weight on the reduction of stroke and death and less on the importance of nonfatal myocardial infarction (MI). Because the latter end point often represents the main benefit of CAS, the recommendations in this document are more circumspect with regard to the role of CAS and more supportive of the role of CEA than the recommendations of the American Heart Association (AHA) guidelines committee. This document is divided into six major sections: IIndications for imaging of the extracranial circulationIISelection of imaging modalityIIIThe importance of medical therapy in the overall management of patients with carotid stenosis, including medical management in the peri-intervention period.IVTechnical considerations for performing CEA and CASVThe relative roles of medical management, CEA and CAS for stroke risk reduction in patients with carotid stenosis based on review of the literature, with particular reference to risk factor stratification and the most recent completed trialsVIThe management of unusual conditions associated with extracranial carotid pathology, including acute neurologic conditions, symptomatic carotid occlusion, carotid dissection, and patients with carotid stenosis in need of coronary artery revascularization The committee reviewed the literature pertinent to each of the six areas and provided recommendations for treatment using the GRADE (Grades of Recommendation Assessment, Development and Evaluation) system.14Murad M.H. Montori V.M. Sidawy A.N. Ascher E. Meissner M.H. Chaikof E.L. et al.Guideline methodology of the Society for Vascular Surgery including the experience with the GRADE framework.J Vasc Surg. 2011; 53: 1375-1380Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar This system, adopted by more than 40 other organizations, incorporates an evaluation of the strength of the evidence and the risks/benefits of implementing the recommendation. For the purposes of this review, we placed the highest priorities on reducing overall stroke risk, periprocedural stroke risk, and periprocedural mortality. Lesser importance was given to reducing nonfatal MI, cost, and the ability to perform a percutaneous procedure. Recommendations are characterized as strong GRADE 1 or weak GRADE 2, based on the quality of evidence, the balance between desirable effects and undesirable ones, the values and preferences, and the resources and costs. GRADE 1 recommendations are meant to identify practices where benefit clearly outweighs risk. These recommendations can be made by clinicians and accepted by patients with a high degree of confidence. GRADE 2 recommendations are made when the benefits and risks are more closely matched and are more dependent on specific clinical scenarios. In general, physician and patient preference plays a more important role in the decision-making process in these circumstances. In addition to the GRADE of recommendation, the level of evidence to support the recommendation is noted. Evidence is divided into 3 categories: A (high quality), B (moderate quality), and C (low quality). Conclusions based on high-quality evidence are unlikely to change with further study, those based on moderate-quality evidence are more likely to be affected by further investigation, and those based on low-quality evidence are the least supported by current data and the most likely to be subject to change in the future. It is important to note that a GRADE 1 recommendation can be made based on low-quality (C) evidence by the effect on patient outcome. For example, although there are little data on the efficacy of CEA in asymptomatic patients with 50%) is seen in 12% to 20% of all anterior circulation ischemic strokes, which is two to three times higher than the risk for less severe asymptomatic stenosis.16Chambers B.R. Donnan G.A. Carotid endarterectomy for asymptomatic carotid stenosis.Cochrane Database Syst Rev. 2005; 4: CD001923PubMed Google Scholar, 17Abbott A.L. Bladin C.F. Levi C.R. Chambers B.R. What should we do with asymptomatic carotid stenosis?.Int J Stroke. 2007; 2: 27-39Crossref PubMed Scopus (36) Google Scholar Unfortunately, only 15% of stroke victims have a warning TIA before stroke, and waiting until symptoms occur is not ideal.18Hankey G.J. Impact of treatment of people with transient ischemic attacks on stroke incidence and public health.Cerebrovasc Dis. 1996; 6: 26-33Crossref Google Scholar The purpose of carotid bifurcation imaging is to detect “stroke-prone” carotid bifurcation plaque and identify a high-risk patient likely to benefit from therapy designed to reduce stroke risk. Stroke risk is dependent on many factors, but for patients with carotid bifurcation disease, the most important are a history of neurologic symptoms, the degree of stenosis of the carotid bifurcation plaque, and to a lesser extent, plaque characteristics such as ulcerations, intraplaque hemorrhage, and lipid content. The North American Symptomatic Carotid Endarterectomy Trial (NASCET) and European Carotid Surgery Trial (ECST) clearly demonstrated the efficacy of CEA in reducing stroke in patients with symptoms of carotid territory cerebral ischemia and carotid bifurcation stenosis that reduced luminal diameter by >50%.2North American Symptomatic Carotid Endarterectomy Trial Collaborators (NASCET)Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators.N Engl J Med. 1991; 325: 445Crossref PubMed Google Scholar, 3Barnett H.J. Taylor D.W. Eliasziw M. Fox A.J. Ferguson G.G. Haynes R.B. et al.Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators.N Engl J Med. 1998; 339: 1415-1425Crossref PubMed Scopus (1782) Google Scholar, 4Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST).Lancet. 1998; 351: 1379-1387Abstract Full Text Full Text PDF PubMed Scopus (1801) Google Scholar In these studies, the risk of stroke was higher in patients with a clear history of carotid territory ischemic events (as opposed to amaurosis fugax), and stroke risk increased with the severity of stenosis. Asymptomatic Carotid Atherosclerosis Study (ACAS) and Asymptomatic Carotid Surgery Trial (ACST)5Endarterectomy for asymptomatic carotid artery stenosis. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study.JAMA. 1995; 273: 1421-1428Crossref PubMed Scopus (0) Google Scholar, 6Halliday A. Mansfield A. Marro J. Peto C. Peto R. Potter J. et al.Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomised controlled trial.Lancet. 2004; 363: 1491-1502Abstract Full Text Full Text PDF PubMed Scopus (1148) Google Scholar found that CEA was also effective in reducing stroke risk in patients with asymptomatic carotid stenosis >60%, although the stroke risk inherent in an asymptomatic stenosis was much less than that in a symptomatic lesion. It follows then that neurologically symptomatic patients and neurologically asymptomatic patients at high risk for harboring a carotid stenosis of ≥60% would be candidates for carotid bifurcation imaging. Typical carotid territory ischemic symptoms include contralateral weakness of the face, arm, or leg, or both; contralateral sensory deficit or paresthesia of the face, arm, or leg, or both; or transient ipsilateral blindness (amaurosis fugax). If the right cerebral hemisphere is involved, other manifestations may be noted, including anosognosia, asomatognosia, neglect, visual, or sensory extinction. If the left hemisphere is involved, patients may show manifestation of aphasia, alexia, anomia, and agraphesthesia. Symptoms not typically associated with carotid territory events include vertigo, ataxia, diplopia, visual disturbances, dysarthria, nausea, vomiting, decreased consciousness, and weakness, which may include quadriparesis. The physical examination may show signs of stroke: facial/eyelid drooping, motor or sensory deficits, and speech disturbances. Ocular examinations can occasionally identify Hollenhorst plaques. Neck auscultation may elicit carotid bruit; however, the absence of a neck bruit does not exclude the possibility of a significant carotid bifurcation lesion. Given the incidence of significant carotid stenosis in patients who present with stroke15Warlow C.P. Dennis M.S. van Gijn J. What caused the transient or persisting ischaemic event.in: Warlow C.P. Stroke a practical guide to management. Blackwell Science, Oxford, Engle2001: 223-300Google Scholar, 19Chaturvedi S. Bruno A. Feasby T. Holloway R. Benavente O. Cohen S.N. et al.Carotid Endarterectomy – an evidence based review: report of the Therapeutics and Technology Subcommittee of the American Academy of Neurology.Neurology. 2005; 65: 794-801Crossref PubMed Scopus (243) Google Scholar and the effectiveness of CEA in reducing stroke in symptomatic patients with >50% carotid stenosis,2North American Symptomatic Carotid Endarterectomy Trial Collaborators (NASCET)Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators.N Engl J Med. 1991; 325: 445Crossref PubMed Google Scholar, 3Barnett H.J. Taylor D.W. Eliasziw M. Fox A.J. Ferguson G.G. Haynes R.B. et al.Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators.N Engl J Med. 1998; 339: 1415-1425Crossref PubMed Scopus (1782) Google Scholar, 4Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST).Lancet. 1998; 351: 1379-1387Abstract Full Text Full Text PDF PubMed Scopus (1801) Google Scholar it is important to evaluate the carotid bifurcation in every patient with symptoms of carotid territory ischemia. Amaurosis fugax or the finding of a Hollenhorst plaque on funduscopic examination, or both, is also correlated with the presence of significant carotid bifurcation stenosis. However, neither amaurosis fugax nor identification of a Hollenhorst plaque are associated with the same stroke risk as transient cerebral ischemia.20Benavente O. Eliasziw M. Streifler J.Y. Fox A.J. Barnett H.J. Meldrum H. et al.Prognosis after transient monocular blindness associated with carotid-artery stenosis.N Engl J Med. 2001; 345: 1084-1090Crossref PubMed Scopus (106) Google Scholar Identification of carotid stenosis in that clinical scenario implies a stroke risk somewhere between a neurologically symptomatic patient and one who is asymptomatic. Evaluation and treatment of patients who are neurologically asymptomatic is much more controversial. The benefit of carotid endarterectomy for stenosis >60%, although statistically significant in large trials, is much less than for neurologically symptomatic individuals and rests on the premise that intervention can be performed with minimal morbidity.5Endarterectomy for asymptomatic carotid artery stenosis. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study.JAMA. 1995; 273: 1421-1428Crossref PubMed Scopus (0) Google Scholar, 6Halliday A. Mansfield A. Marro J. Peto C. Peto R. Potter J. et al.Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomised controlled trial.Lancet. 2004; 363: 1491-1502Abstract Full Text Full Text PDF PubMed Scopus (1148) Google Scholar Identification of these asymptomatic patients may occur by routine scr
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