We need to revise management guidelines of asymptomatic carotid

atheroma

Guy-André Pelouze MDChirurgien des Hôpitaux

Perpignan

France

Asymptomatic carotid atheroma

• Carotid: which means bifurcation and doesn’tmean main carotid, brachiocephalic, subclavian or vertebral arteries.

• Atheroma: of the bifurcation which doesn’tmean restenosis, radiation-induced lesion, fibrodysplasia

• Asymptomatic: which means no focal, ipsilateral neurological or ocular symptomduring the past six months

The risk of stroke associated with asymptomatic atheroma of carotid bifurcation has fallen

drastically

• BMT (Statin/AP/ACE inhibitors) alone reduces the risk at least of 60-80%

• Arteriography no longer mandatory in thosepatients, Duplex and angioCT don’t provokestroke and provide more reliable imaging

• Trials comparing CEA vs BMT had not taken in account present BMT because there werecompleted previous statin therapy

• Carotid endarterectomy or carotid artery stentingwill not likely benefit today asymptomaticpatients unless new RCT prove it

What is BMT?

• Lifestyle changes: smoking cessation, med diet, exercise

• Statins with achieved goal about LDL cholesteroland complementary lipid lowering drugs if necessary

• Antiplatelet therapy with aspirin or clopidogrel

• ACE inhibitors with achieved goal of normalizedarterial pressure during a 24h period

27 guidelines on asymptomatic carotidatheromatous stenosis

Number of studies % of studies Recommendation (Carotid endarterectomy CEA, Carotid artery stenting CAS)

7 26 Strong advocates for CEA

16 59 Weak advocates for CEA

2 7 Strong advocates for CAS

11 41 Weak advocates for CAS

7 26 Strong advocates AGAINST CAS

12 44 Some support for CAS only in patients with highrisk CEA due to vascular anomaly

10 37 Some support for CAS only in patients with highrisk CEA due to comorbidities

Adapted from:http://www.vascularnews.com/vn-newspaper-pdfs?DocumentScreen=detail&cl=539&ccs=655

Recommendations: time dependent or bias variations ? (1)

• NASCET : North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade stenosis. N Engl J Med. 1991;325:445–453.

• ACAS: Walker MD, Marler JR, Goldstein M, et al. Endarterectomy for Asymptomatic Carotid Artery Stenosis. JAMA. 1995;273(18):1421-1428. doi:10.1001/jama.1995.03520420037035.

• SPARCL: Amarenco P, et al. High-dose atorvastatin after stroke or transient ischemic attack. N Engl J Med. 2006. 355(6):549-559.

Recommendations: time dependent or bias variations ? (2)

• BMT is not complete in at least 30% of patients

• CEA could reduce by 0.5-1% RRR in asymptomaticpatients if patient Life Expectancy exceeds 3 years

• Routine practice shows that recommendations are not followed in approx. 50% of cases either by misleadingmeasures, error in the status (symptomatic versus asymptomatic), or other bias

• Choice between CEA vs CAS is mainly driven by the training of the interventionist rather than evidence

• Industry is powerfully backing CAS because of the costof implanted material versus CEA

Conclusion

• CAS for asymptomatic patients is not indicated exceptfor rare cases of stenosis progression

• CEA for asymptomatic patients is 60-70% of the workload in vascular surgical centers in Europe (except UK) or US

• There is clearly a better possibility for allocation of these resources

• Instead vascular surgical centers should get togetherwith stroke centers to improve symptomatic patient management and care in terms of delay and results

• CAS does have a future in asymptomatic patients but itbelongs to RCT