Maybe asymptomatic carotid disease is not as benign as we think.

Abstract

In this issue of JVS, Turner et al1Turner A.D. Zhu J. Rao A. Ting W. Han D. Tadros R. et al.Carotid stenosis patients with a remote history of cerebrovascular events have increased risk of major adverse events over asymptomatic patients.J Vasc Surg. 2022; 76: 1625-1632Google Scholar provide some additional insight into the impact of a remote history of cerebrovascular events as a marker for increased periprocedural adverse events after carotid stenting. The default definition of “asymptomatic” extracranial carotid disease is the absence of clinical signs and symptoms of a transient ischemic attack or stroke. As this report shows, although most asymptomatic patients are truly asymptomatic, a subset do indeed have a prior history of a neurologic event that occurred more than 180 days before an intervention but are still typically categorized as asymptomatic. This current report demonstrates that at least among patients treated with carotid stenting (transfemoral vs transcarotid), the periprocedural outcomes more closely resemble the symptomatic rather than the asymptomatic patient population. For years, we have tried a variety of imaging techniques to identify the unstable asymptomatic plaque including computed tomographic evaluation, magnetic resonance plaque characterization, ultrasound gray scale median, and transcranial Doppler.2Kakkos S.K. Griffin M.B. Nicolaides A.N. Kyriacou E. Sabetai M.M. Tegos T. et al.Asymptomatic Carotid Stenosis and Risk of Stroke (ACSRS) study group. The size of juxtaluminal hypoechoic area in ultrasound images of asymptomatic carotid plaques predicts the occurrence of stroke.J Vasc Surg. 2013; 57 (discussion: 617-8): 609-618.e1Abstract Full Text Full Text PDF PubMed Scopus (127) Google Scholar,3Saba L. Antignani P.L. Gupta A. Cau R. Paraskevas K.I. Poredos P. et al.International Union of Angiology (IUA) consensus paper on imaging strategies in atherosclerotic carotid artery imaging: from basic strategies to advanced approaches.Atherosclerosis. 2022; 354: 23-40Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar Unfortunately, none are broadly recognized as an accurate predictor. In my institution, transcranial Doppler is used quite frequently by the stroke neurologists, yet it has not made a noticeable impact on the current treatment algorithm for most patients. Hopefully, upcoming prospective studies such as the Carotid Artery Multimodality imaging Prognostic study may provide more valuable insight of the unstable asymptomatic plaque with contemporary imaging techniques.4Gargani L. Baldini M. Berchiolli R. Bort I.R. Casolo G. Chiappino D. et al.Detecting the vulnerable carotid plaque: the Carotid Artery Multimodality imaging Prognostic study design.J Cardiovasc Med (Hagerstown). 2022; 23: 466-473Crossref Scopus (1) Google Scholar Although the current report demonstrates improved outcomes among the transcarotid treated patient population vs transfemoral stenting using the Vascular Quality Initiative database, some concerns exist in regard to the data quality and sample size. Important unknowns include adherence and implementation of currently accepted optimal medical therapy, operator expertise, and objective neurologic assessment before and after the procedure. Nevertheless, the important message is that asymptomatic patients with any prior history of a remote neurologic event tend to have less favorable outcomes as compared those with no prior history of a neurologic event, and this information should be taken into consideration as part of the treatment algorithm. The opinions or views expressed in this commentary are those of the authors and do not necessarily reflect the opinions or recommendations of the Journal of Vascular Surgery or the Society for Vascular Surgery. Carotid stenosis patients with a remote history of cerebrovascular events have increased risk of major adverse events over asymptomatic patientsJournal of Vascular SurgeryVol. 76Issue 6PreviewAsymptomatic patients with a remote history of transient ischemic attack (TIA) or stroke are not well studied as a separate population from asymptomatic patients with no prior history of TIA or stroke. We compared in-hospital outcomes after transcarotid artery revascularization (TCAR) and transfemoral carotid artery stenting (TFCAS) among symptomatic patients, patients with a remote history of neurologic symptoms, and asymptomatic patients. Full-Text PDF