Results Of Endarterectomy Research Articles

The Effect of Preoperative Smoking Status on Carotid Endarterectomy Outcomes in Asymptomatic Patients

The current medical landscape lacks comprehensive data regarding the impact of preoperative smoking status on both short and long-term outcomes for patients undergoing Carotid Endarterectomy (CEA). This study seeks to elucidate the influence of smoking cessation on in-hospital and long-term outcomes in this patient population. Data were collected from the Vascular Quality Initiative (VQI) for all asymptomatic patients who underwent CEA from 2016 to 2023. Outcomes were compared across three different smoking status groups: never smoke (NS), current smoker (CS), and quit >30 days ago (Q30). Our primary outcomes included: in-hospital stroke, death, and MI. Secondary outcomes included 1-year and 3-year death. We used inverse probability of treatment weighting (IPTW) to balance the following preoperative factors: age, gender, race, ethnicity, BMI, diabetes, CAD, prior CHF, renal dysfunction, COPD, HTN, prior CABG/PCI, prior CEA/CAS, degree of stenosis, urgency, anesthesia type, and medications. The final analysis included 85,237 CEA cases with 22,343 (26.2%) NS, 41,731 (49.0%) Q30, and 21,163 (24.8%) CS. Notably, NS tended to be older and more likely to be female. On the other hand, patients who Q30 were more likely to have comorbidities including: obesity, CAD, prior CHF, CKD, as well as prior procedures. Patients who are CS were more likely to have COPD and stenosis >80%. After IPTW, we found no statistical difference for in-hospital stroke, death, MI outcomes across the three groups. However, the long-term outcomes revealed Q30 and CS compared to NS had higher odds of 1-year death (OR= 1.4 [95% CI: 1.2-1.5] P<0.001; OR= 1.4 [95% CI: 1.2-1.6] P<0.001) and 3-year death (OR= 1.5 [95% CI: 1.3-1.6] P<0.001; OR= 1.5 [95% CI: 1.4-1.7] P<0.001), respectively. There was no significant difference in mid-term mortality outcomes between Q30 and CS. In this large national study, we found that smoking status did not emerge as a substantial determinant of adverse short-term outcomes for asymptomatic patients undergoing CEA. However, smoking did adversely affect mid-term mortality in these patients. In light of these findings, our study suggests that delaying CEA for smokers may not be warranted. It is crucial to recognize that the complex relationship between smoking and surgical outcomes requires further exploration and validation through additional prospective studies.

Letter to the editor regarding "Carotid endarterectomy outcomes according to anesthesia method: General anesthesia or regional anesthesia"

Letter to the editor regarding "Carotid endarterectomy outcomes according to anesthesia method: General anesthesia or regional anesthesia"

Pre-operative Smoking Cessation Improves Carotid Endarterectomy Outcomes in Asymptomatic Carotid Stenosis Patients

ObjectiveSmoking cessation has been suggested as having the potential to improve the outcomes of carotid endarterectomy (CEA) and mitigate the risk of long-term stroke in patients with asymptomatic carotid stenosis (ACS). This study aims to compare the peri-operative and long-term outcomes of CEA in ACS patients across different smoking status groups. MethodsAll patients receiving an elective CEA for ACS between 2013 and 2023 were identified in the Vascular Quality Initiative (VQI). Patients with an ipsilateral carotid stenosis <70% and those receiving a concomitant coronary artery bypass graft (CABG) were excluded. Patients were then classified according to their smoking status: never smokers, former smokers (defined as those who have stopped smoking more than 30 days prior to their operation), and current smokers. Patient characteristics and outcomes were compared using the χ2 or Fischer’s exact test as appropriate for categorical variables and the ANOVA or Kruskal-Wallis test as appropriate for continuous variables. Cox-regression analysis was used to study the association between smoking status and the primary outcomes of long-term stroke and major adverse cardiac events (MACE) defined as the composite outcome of stroke, MI, and/or mortality. ResultsA total of 77,664 patients received a CEA for ACS, of which 19,416 (25%) patients were never smokers, 39,374 (51%) patients were former smokers, and 18,874 (24%) patients were current smokers. Patients in the three groups had similar rates of perioperative stroke (p=0.79), myocardial infarction (p=0.07), mortality (p=0.23), and MACE (p=0.17). At 18-month follow up, former and never smokers had similar rates of stroke (former 0.9% vs never 0.8%, p=0.92), with former smokers exhibiting a lower stroke risk than current smokers (former 0.9% vs current 1.5%, p=0.001). At 18 months, former smokers had a significantly lower rate of MACE compared to current smokers (former 11.8% vs current 13.2%, p=0.03), but a higher rate compared to never smokers (former 11.8% vs never 8.7%, p<0.001). On multivariate Cox-regression analysis, compared to current smokers, former smokers were independently associated with a lower risk of stroke (HR 0.68, 95% CI 0.53–0.87, p=0.002), mortality (HR 0.79, 95% CI 0.74–0.84, p<0.001), and MACE (HR 0.77, 95% CI 0.70–0.83, p<0.001). No difference in long-term stroke risk was observed between former and never smokers (HR 1.06, 95% CI 0.82–1.38, p=0.65). ConclusionThis study demonstrates that preoperative smoking cessation in ACS patients significantly reduces the risk of stroke, mortality, and MACE following CEA compared to continued smoking, aligning their outcomes more closely with those of never smokers. Optimizing ACS patients prior to surgery should include smoking cessation counseling. Vascular surgeons play a critical role in encouraging smoking cessation, as their guidance can significantly improve patient outcomes following CEA.

Navigating Surgical Risks: The Impact of BMI Outliers on Pulmonary Endarterectomy Outcomes

Navigating Surgical Risks: The Impact of BMI Outliers on Pulmonary Endarterectomy Outcomes

Periprocedural clinical outcomes of stenting and endarterectomy in patients with carotid artery stenosis

Purpose: To identify the chief pathological cause of extracranial cerebrovascular disease, which is atherosclerosis, we analyzed and compared the early and 6-month morbidity and mortality rates of patients who underwent carotid endarterectomy (CEA) and carotid artery stenting (CAS) for carotid artery stenosis. Materials and Methods: We retrospectively included patients who had undergone surgical endarterectomy and endovascular carotid stent implantation for carotid artery stenosis between April 2019 and August 2022. We evaluated neurological examinations, routine blood tests, neurological and systemic complications, mortality rates, and follow-up colour Doppler ultrasonography 6 months post-discharge. Results: The study included a total of 300 patients, with 52.7% (n = 158) undergoing CEA and 47.3% (n = 142) undergoing endovascular stent implantation (CAS). The patients’ average ages were 66±8 years in the CEA group and 70±7.4 years in the CAS group, suggesting that those undergoing CAS were generally older. Notably, there were significantly more instances of congestive heart failure and a history of cerebrovascular disease within the CAS group compared to the CEA group. However, no significant difference was observed in the rates of postprocedural complications. Furthermore, there were no cases of mortality reported in either group. Conclusion: The preferred method for treating severe carotid artery stenosis should be determined by considering patient characteristics and preferences, as well as the complication rates in the centre.

Carotid endarterectomy outcomes according to anesthesia method: General anesthesia or regional anesthesia?

Aim: Surgical strategies in carotid endarterectomy (CEA) vary according to the method of anesthesia, neurological monitoring, shunt use, and closure methods, and the gold standard method has not yet been determined. In this study, we aimed to analyze the superiority and feasibility of CEA under general anesthesia and regional anesthesia. Material and Methods: Demographic characteristics, operative information and follow-up results of 237 patients who underwent CEA between January 2015 and June 2020, 165 patients under regional anesthesia (RA: Group 1) and 72 under general anesthesia (GA: Group 2), were retrospectively analyzed. In Group 1, carotid shunt was placed in patients with a negative awake test (n: 21, 12.7%) and in Group 2 carotid shunt was placed in all cases. Results: There was no statistically significant difference in postoperative stroke, transient ischemic attack (TIA) and cardiovascular mortality (p: 0.48; p: 0.30; p: 0.63, respectively). Although the operation and clamp time were shorter in Group 1, no significant difference was observed (97.93±11.02 min, 101.46±9.49 min p: 0.23; 19.60±5.62 min, 25.62±7.47 min p: 0.24, respectively). The duration of intensive care unit (ICU) stay was shorter and statistically significant in Group 1. (p: 0.003). There was no significant difference for restenosis rates (p: 0.34). Conclusion: There was no significant increase in postoperative complications in the RA group compared to the GA group despite shunting according to the awake test. Also, patients who underwent RA stayed in ICU for a shorter period of time. CEA can be performed under both GA and RA with similar complication rates.

Outcomes of pulmonary endarterectomy for patients with pulmonary artery sarcoma.

Pulmonary artery sarcoma (PAS) is an exceedingly rare and insufficiently investigated disease, leading to uncertain in its optimal management. This study aims to present our institutional experience and the outcomes of pulmonary endarterectomy for PAS. We gathered clinical characteristics, intraoperative data, postoperative outcomes, and prognosis information from PAS patients who underwent surgical treatment at our institution between December 2016 and September 2023. A total of 20 patients with PAS underwent pulmonary endarterectomy. The median age of the patients was 52 (IQR 45, 57) years, with 12 patients (60%) being female. Intimal sarcoma was confirmed in 19 patients, while the remaining one was diagnosed with large cell neuroendocrine carcinoma. The perioperative mortality rate was three cases (15%). Follow-up was conducted for a median duration of 14 months (range: 1-61). During the follow-up period, 11 patients experienced recurrence or metastasis, and 5 patients succumbed to the disease. The estimated cumulative survival rates at 1 and 2 years for all 20 patients were 66.4% and 55.3%, respectively. Pulmonary endarterectomy emerges as a palliative but effective approach for managing PAS, particularly when complemented with postoperative therapies such as chemotherapy and targeted therapy, which collectively contribute to achieving favorable long-term survival outcomes.

Open surgery of common femoral artery occlusive disease: a contemporary review.

Endovascular therapy has gradually gaining more importance for the treatment of common femoral artery (CFA) occlusive disease due to satisfactory perioperative outcomes. However, endovascular interventions seem to provide acceptable outcomes only in the short-term period. Endarterectomy still remains the gold standard with well-established mid- and long-term outcomes. The aim of this study was to analyze all appropriate studies about mid- and long-term outcomes of CFA endarterectomy, regardless of the type of technique used in the framework of a narrative contemporary review. This narrative review was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The main inclusion criterion was the availability of data on isolated CFA endarterectomy including mid (1-5 years) and long (6-10 years) term results. Four studies have been selected. In the mid-term period CFA endarterectomy showed an excellent primary patency rate regardless the clinical presentation (up to 95% and 100% in intermittent claudication and chronic limb-threatening ischemia). About the type of reconstruction, a statistically significant difference was found between patchplasty and direct suture in terms of primary patency (97% vs. 89.9%, P=0.02). In the long-term period the overall primary patency rate was about 95%, regardless of the clinical condition (P=0.04). Overall long-term limb salvage rate ranged from 87% to 92%, with a relatively significant difference between intermittent claudication (100%), and chronic limb-threatening ischemia (82%) (P=0.01). Considering long-term clinical outcomes and the subsequent durability, surgical treatment is still the cornerstone for CFA occlusive disease, regardless of the type of technique used for both endarterectomy and arterial reconstruction. Due to its reduced invasiveness, high-risk patients may benefit from an endovascular-first approach.

F-31 | Outcomes of Pulmonary Endarterectomy in Patients with Systolic Heart Failure

F-31 | Outcomes of Pulmonary Endarterectomy in Patients with Systolic Heart Failure

Intraoperative Completion Studies and their Associations with Carotid Endarterectomy Outcomes.

This study aimed at assessing outcomes after carotid endarterectomy (CEA) in dependence of center policy with respect to imaging intraoperative completion study (ICSi) usage. Although randomized controlled studies are missing, a beneficial effect was shown for ICSi techniques (i.e., angiography and intraoperative duplex ultrasound) after CEA. This secondary data analysis is based on the German statutory quality assurance database. Research was funded by Germany's Federal Joint Committee Innovation Fund (G-BA Innovationsfonds, 01VSF19016 ISAR-IQ). According to their ICSi policy, hospitals were categorized as routine ICSi (>90%), selective ICSi (10-90%), or sporadic ICSi (<10%) centers. Primary study outcome was in-hospital stroke or death. Multivariable regression analyses were performed. Between 2012 and 2016, a total of 119,800 patients underwent CEA. In-hospital stroke or death rates were lower in routine ICSicenters (1.7%) compared to selective (2.1%) and sporadic ICSicenters (2.0%). The multivariable regression analysis showed, that in routine ICSicenters, ICSi use was associated with lower rates of stroke or death (aOR 0.64; 95% CI 0.44-0.93). In selective ICSicenters, ICSi was not associated with the occurrence of either of the assessed outcomes. In sporadic ICSicenters, ICSi was associated with higher rates of stroke or death (aOR 1.91; 95% CI 1.26-2.91). Lowest in-hospital stroke or death rates are achieved in routine ICSicenters. While ICSi is associated with a lower perioperative risk in routine ICSicenters, it might act as a surrogate marker for worse outcomes due to intraoperative irregularities in sporadic ICSicenters. Routine use of ICSi is advisable.

Early Outcomes of Interwoven Nitinol Wire Stent Placement versus Endarterectomy for the Treatment of Atherosclerotic Disease of the Common Femoral Artery

PurposeTo compare the clinical outcomes of common femoral artery (CFA) atherosclerotic disease treated with either surgical endarterectomy or an interwoven nitinol wire stent system. Materials and MethodsA retrospective review was conducted of all patients with chronic, de novo atherosclerotic CFA disease treated with surgical endarterectomy (CFAE) or stent placement between July 2019 and March 2022. Outcome measures assessed up to 12 months after procedure included clinical improvement, primary restenosis, target vessel revascularization (TVR), major adverse limb events (MALEs), and all-cause mortality. ResultsThirty-nine stents were deployed in 33 patients, and 56 CFAEs were performed in 55 patients. No differences were noted in the rate of primary patency (95.5% vs 94.4%, P = .618), TVR (2.9% vs 1.8%, P = .777), MALE (5.1% vs 5.4%, P = .949), and all-cause mortality (14.1% vs 3.6%, P = .076) between the stent and CFAE groups up to 12 months after procedure. There was greater improvement in median clinical severity in the stent group than in the CFAE group (Rutherford score change of 3.0 vs 1.5, P = .013). The median length of stay was less for the stent group (3 vs 7 days, P = .002), and there was a lower likelihood of severe or disabling adverse events in the stent group (0 vs 9 cases, P = .010). ConclusionsPatients treated with an interwoven nitinol wire stent had patency rates comparable to those treated with CFAE while having a lower incidence of severe adverse events and a shorter length of hospital stay than those who underwent CFAE.

Outcomes of Coronary Endarterectomy for Patients With Diffuse Coronary Artery Disease: A Single-Centre Retrospective Study

Incidence of diffuse coronary artery disease is high in Asian population. Some patients will require endarterectomy for completeness of revascularisation. This series aimed to investigate the outcomes of patients who required coronary endarterectomy (CE) either in one or multiple vessels.

O065 Does modified Rankin score (mRS) matter? the impact of stroke severity on carotid endarterectomy (CEA) outcomes

Abstract Introduction Carotid endarterectomy (CEA) is recommended to reduce the risk of future stroke in patients with non-disabling ischaemic stroke events (modified Rankin Score mRS&amp;lt;3). We reviewed CEA outcomes in patients with more devastating consequences of stroke (mRS 3+). Methods Data from 1021 consecutive CEA cases at a single unit were collected from the UK National Vascular Registry, over a 15-year period. Patient demographics, co-morbidities and postoperative outcomes were compared in those with pre-operative mRS &amp;lt;3 (Group 1) and those with mRS 3+ (Group 2). P&amp;lt;0.05 was considered significant. Results 91 (9%) patients with mRS 3+ underwent CEA. Age, gender ratio and operated side were not significantly different between the two groups. Group 2 had significantly higher rates of diabetes, atrial fibrillation, renal failure, lung disease, frailty and a higher ASA score. Time to surgery from the stroke event was similar in the two groups, but time spent on high dependency and overall in hospital following surgery was longer in Group 2. There was no difference in the type of anaesthetic given. Group 2 had a higher incidence of postoperative confusion, but there was no significant difference between the two groups in cardiac, respiratory, operative complications and 30-day mortality. Fewer patients in Group 2 returned to their home on discharge. Conclusion Patients with a higher mRS are frailer and have more pre-operative co-morbidities. Surgery is associated with delayed discharges, but in the short-term, perioperative complication rate is not significantly different. Patient selection, however, should be undertaken withcare.

Effect of the Pre-Operative Systemic Inflammatory Response on Outcomes Following Carotid Endarterectomy for Symptomatic Carotid Stenosis

Objective: Stroke accounts for over 100 000 acute hospital presentations per year in the UK, and approximately 4 500 carotid endarterectomies are performed annually in the UK.1 This is despite a relative paucity of cases performed for asymptomatic carotid stenosis, in comparison with other countries.1 Periprocedural stroke and death rates have fallen in recent years,2 although these remain notable risks necessitating careful patient selection and counselling. Chronic activation of the systemic inflammatory response (SIR) is prevalent in patients with atherosclerotic disease and influences both the pathogenesis and prognosis.3,4 The neutrophil:lymphocyte and platelet:lymphocyte ratios (NLR, PLR) are markers of the SIR, and are reported to provide prognostic value in patients with acute stroke,5 and in patients undergoing carotid endarterectomy.6 The Modified Glasgow Prognostic Score (mGPS) is calculated from C-reactive protein (CRP) and albumin and was originally described in patients with cancer.7 More recently mGPS has been shown to provide prognostic value in non-cancer patient groups.8 mGPS is representative of an alternative pathway activating the SIR and is not reported in relation to carotid endarterectomy outcomes. The present study describes experience of the prognostic value of these pre-operative markers of SIR in patients undergoing carotid endarterectomy.

Effect of regional versus general anesthesia on thirty-day outcomes following carotid endarterectomy: a cohort study.

The effect of regional versus general anesthesia on carotid endarterectomy outcomes is debated. This study assesses the effect of anesthetic technique on major morbidity and mortality and additional secondary endpoints following carotid endarterectomy. This was a retrospective propensity-matched-cohort analysis investigating elective carotid endarterectomy patients in the 2015-2019 American College of Surgeons National Surgical Quality Improvement Program ( n =37204). The primary endpoint was 30-day mortality and major morbidity, defined as stroke, myocardial infarction, or death. Secondary endpoints included minor morbidity, bleeding events, healthcare resource utilization, and length of hospital stay. Univariate, multivariable, and survival analyses were applied. The 1:1 propensity-matched-cohort included 8304 patients (4152 in each group). Regional anesthesia was associated with similar incidences of major morbidity and mortality [odds ratio (OR), 0.81 (95% CI, 0.61-1.09); P = 0.162] and unplanned resource utilization [OR, 0.93 (95% CI, 0.78-1.11); P = 0.443], but lower incidences of minor morbidity [OR, 0.60 (95% CI, 0.44-0.81); P < 0.001] and bleeding events [OR, 0.49 (95% CI, 0.30-0.78); P = 0.002], and a shorter length of hospital stay [1.4 vs. 1.6 days; mean difference, -0.16 days (95% CI, -0.25 to -0.07); P < 0.001]. On multivariable analysis, regional anesthesia remained independently predictive of minor morbidity [adjusted odds ratio (AOR), 0.58 (95% CI, 0.42-0.79); P = 0.001] and bleeding events [AOR, 0.49 (95% CI, 0.30-0.77); P = 0.003]. Significance was maintained on survival analysis for these two endpoints. A mortality benefit was observed on univariate [OR, 0.50 (95% CI, 0.25-1.00); P = 0.045], multivariable [AOR, 0.49 (95% CI, 0.24-0.96); P = 0.043], and survival analysis ( P = 0.045). Carotid endarterectomy patients receiving regional anesthesia experience favorable outcomes compared to propensity-matched general anesthesia controls.

Does Modified Rankin Score (mRS) Matter? The Impact of Stroke Severity on Carotid Artery Endarterectomy (CEA) Outcomes

Carotid artery endarterectomy (CEA) is recommended to reduce stroke risk in patients following non-disabling ischaemic stroke (modified Rankin Score mRS<3). We reviewed CEA outcomes in patients after more devastating strokes (mRS≥3). An observational cohort study was performed, and data was collected from 1013 CEA cases over fifteen years. Patient demographics, co-morbidities and post-operative outcomes were compared between preoperative mRS<3 (Group one) and mRS≥3 (Group two). Statistical significance was determined by p<0.05. Ninety-one (9%) patients were mRS ≥ 3. There was no significant difference between age, gender, and operated side. Group two had significantly higher rates of diabetes and frailty. There was no significant difference in anaesthetic type. Group two spent longer in High Dependency. Return to theatre and post-operative complications were similar. Incidence of perioperative stroke, mortality and readmission rates were not significant at 30 days post-operation between the two groups. Patients with a higher mRS have more pre-operative co-morbidities but short-term perioperative complication rate is not significantly different. Patient selection should be undertaken with care.

Clinical Outcomes of Endoscope-Assisted Pulmonary Endarterectomy for Chronic Thromboembolic Pulmonary Hypertension.

Pulmonary thromboembolism is a potentially life-threatening condition in patients with heart disease; however, limited studies discussing long-term outcomes exist. This study aimed to investigate the long-term outcomes of pulmonary endarterectomy (PEA) in patients with chronic thromboembolic pulmonary hypertension (CTEPH), focusing on the improvement of functional class and right ventricular (RV) pressure. Clinical data of patients with CTEPH were obtained from Yonsei Hospital between May 2012 and December 2021, and reviewed retrospectively. Twenty-six patients underwent endoscope-guided PEA during the study period, and the mean follow-up duration was 24.8±23.4 months. After PEA, most patients (88.5%) were weaned from inotropes without extracorporeal membrane oxygenation support during the first few days. Two patients (7.6%) had cerebrovascular accidents without neurological deficits. On echocardiography, the RV systolic pressure and tricuspid regurgitation grades significantly improved (p<0.001). Furthermore, the mean left ventricle end-diastolic diameter was significant increased (p=0.003), and the left ventricular end-systolic diameter increased (p<0.001). The median intensive care unit stay was 3.0±9.4 days, and median hospital stay 16.0±26.5 days. The 5-year survival rate was 95.5%, and the 5-year freedom rate of cardiac death was 100%. There was a marked improvement in New York Heart Association (NYHA) status (p<0.001). Cox regression suggested that the main pulmonary artery (MPA) involvement is a significant predictor of non-improvement in functional class post-PEA. Mortality rates are low and patients experience a marked improvement in NYHA class and health status after PEA. Moreover, MPA involvement may affect functional outcomes.

Outcomes of Femoral Endarterectomy with Superficial Tributary Vein Patch Angioplasty

Surgical endarterectomy is still considered the gold standard for the treatment of common femoral artery (CFA) occlusive disease. The present study evaluated the outcomes of CFA endarterectomy with patch angioplasty using the superficial tributary vein (STV) of the great saphenous vein. This was a single-center, retrospective study. We reviewed our institutional data of consecutive patients who received elective CFA endarterectomy between January 2014 and December2021. During the study period, CFA endarterectomy with STV patch angioplasty was performed in 49 limbs in 42 patients, including 33 limbs (67.3%) treated by hybrid procedure combining CFA endarterectomy with endovascular treatment. Technical success was achieved in 100% of subjects. The median ankle brachial pressure index improved from 0.57 (0.43-0.67) preoperatively to 0.96 (0.77-0.99) postoperatively (P<0.001). The 30-day mortality rate was 2.0% (n=1). The overall 30-day complication rate was 6.1% (n=3) and the local complication rate was 2.0% (n=1). No aneurysmal dilatation or rupture of an STV patch was observed at a median follow-up of 22months. The 1-year and 2-year primary patency rates were 97.4% and 97.4%, respectively. The efficacy and patency of CFA endarterectomy with STV patch angioplasty were similar to those of conventional CFA endarterectomy. STV patch angioplasty is a durable procedure and may improve the outcomes of CFA endarterectomy through a reduction in the risk of postoperative local complications by avoiding the use of a prosthetic patch and by preserving the main great saphenous vein.

Treatment of asymptomatic carotid artery stenosis

There is much debate about the best approach for treating patients with tight (at least 70%) asymptomatic carotid artery stenosis. A pooled analysis of trials in recently symptomatic patients with carotid artery stenosis showed that successful, uncomplicated surgery or stenting had similar long-term outcomes for at least 8 years, but early post-procedural strokes were more common after stenting than surgery. 1 Brott TG Calvet D Howard G et al. Long-term outcomes of stenting and endarterectomy for symptomatic carotid stenosis: a preplanned pooled analysis of individual patient data. Lancet Neurol. 2019; 18: 348-356 Summary Full Text Full Text PDF PubMed Scopus (57) Google Scholar The ACST-2 trial reported that, for asymptomatic patients, both procedures had similar procedural and 5-year follow-up outcomes. 2 Halliday A Bulbulia R Bonati LH et al. Second asymptomatic carotid surgery trial (ACST-2): a randomised comparison of carotid artery stenting versus carotid endarterectomy. Lancet. 2021; 398: 1065-1073 Summary Full Text Full Text PDF PubMed Scopus (47) Google Scholar However, medical treatment for asymptomatic carotid artery stenosis has improved substantially in the past 20 years, when many clinical trials in this population were done, and best medical treatment could now be an option instead of more invasive approaches. Carotid endarterectomy or stenting or best medical treatment alone for moderate-to-severe asymptomatic carotid artery stenosis: 5-year results of a multicentre, randomised controlled trialCEA plus BMT or CAS plus BMT were not found to be superior to BMT alone regarding risk of any stroke or death within 30 days or ipsilateral stroke during the 5-year observation period. Because of the small sample size, results should be interpreted with caution. Full-Text PDF

Extra-Cranial Carotid Artery Stenosis: An Objective Analysis of the Available Evidence.

Background and PurposeCarotid stenosis is arterial disease narrowing of the origin of the internal carotid artery (main brain artery). Knowing how to best manage this is imperative because it is common in older people and an important cause of stroke. Inappropriately high expectations have grown regarding the value of carotid artery procedures, such as surgery (endarterectomy) and stenting, for lowering the stroke risk associated with carotid stenosis. Meanwhile, the improving and predominant value of medical intervention (lifestyle coaching and medication) continues to be underappreciated.Methods and ResultsThis article aims to be an objective presentation and discussion of the scientific literature critical for decision making when the primary goal is to optimize patient outcome. This compilation follows from many years of author scrutiny to separate fact from fiction. Common sense conclusions are drawn from factual statements backed by original citations. Detailed research methodology is given in cited papers. This article has been written in plain language given the importance of the general public understanding this topic. Issues covered include key terminology and the economic impact of carotid stenosis. There is a summary of the evidence-base regarding the efficacy and safety of procedural and medical (non-invasive) interventions for both asymptomatic and symptomatic patients. Conclusions are drawn with respect to current best management and research priorities. Several “furphies” (misconceptions) are exposed that are commonly used to make carotid stenting and endarterectomy outcomes appear similar. Ongoing randomized trials are mentioned and why they are unlikely to identify a routine practice indication for carotid artery procedures. There is a discussion of relevant worldwide guidelines regarding carotid artery procedures, including how they should be improved. There is an outline of systematic changes that are resulting in better application of the evidence-base.ConclusionThe cornerstone of stroke prevention is medical intervention given it is non-invasive and protects against all arterial disease complications in all at risk. The “big” question is, does a carotid artery procedure add patient benefit in the modern era and, if so, for whom?