In this episode we delve into the interesting world of carotid artery disease and discuss our management of patients who are asymptomatic. See Yogi's (amazing) crib notes below:

Why do we care about asymptomatic carotid artery disease?

About 10 to 15% of all first ever stroke patients will experience an unheralded ischaemic, carotid territory stroke following thromboembolism from a previously untreated asymptomatic significant carotid disease

Oxford Vascular Study

Enrolled 2354 consecutive patients including 207 with 50 to 99% carotid stenosis

The ipsilateral stroke rate at 5 years for the patients with 70% to 99% was 14.6% compared with 0% for 50 to 50%) and severe (>70%) stenoses in a population of 23,706 people (mean age of 61 years, 46% male) was 2.0% and 0.5% respectively

Moderate stenosis > 50% found in 4.8% of men and 2.2% of women younger than 70 years

The percentage increase to 12.5% in men and 6.9% in women if patients older than 70 years are considered

Severe asymptomatic stenosis (>70%) indicate that its prevalence ranges from 0% to 3.1% of general population

Seminal Trials

Seminal trials have demonstrated a marginal but definitive benefit for CEA in reducing the risk of stroke after 5 and 10 years when compared with “best medical therapy” alone. However, these studies conducted in the late 1980s and in the 1990s, and since their completion, progress in the medical management of cardiovascular diseases has led to a progressive decrease in the yearly risk of stroke in patients with asymptomatic carotid artery stenosis managed with medical treatment alone.

Veterans Affairs Cooperative Study (VACS) [1983 and 1987]

440 men with asymptomatic >50% carotid stenosis were randomised to CEA plus medical management versus medical management only CEA significantly reduced the combined incidence of ipsilateral neurologic events (stroke or TIA) compared to medical group (8.0% vs. 20.6% respectively)

ACAS

1662 patients with asymptomatic >60% carotid stenosis were randomised to medical therapy versus CEA plus medical therapy

Across the United States and Canada

The study was stopped early, after a median follow up of 2.7 years

Patients in the surgical arm had a 5.1% risk of ipsilateral stroke and preoperative stroke/death over 5 years versus 11.0% risk of ipsilateral stroke in the medical arm for a relative risk reduction of 53%; absolute risk reduction of 5.9%

Recommended CEA for patients aged 3%

ACST-1

3120 patients with asymptomatic >60% carotid stenosis were randomised to either immediate CEA or deferred CEA

Asymptomatic patients were considered those without neurological symptoms during the 6 months preceding enrolment

Patients in the immediate CEA group had a significantly reduced five year and 10 year risk of any stroke and peri-operative stroke/death than the deferred CEA group (5 year, 6.9% vs. 10.9%, 10 year 13.4% vs. 17.9%)

An absolute risk reduction of 5.4% was seen in the rate of any stroke and...

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Erscheinungs­datum: 7.2.2022, 21:00:00