Management of asymptomatic carotid atherosclerotic disease
- Emile R Mohler III, MD
Emile R Mohler III, MD
- Section Editor — Vascular Medicine
- Professor of Medicine
- University of Pennsylvania School of Medicine
- Ronald M Fairman, MD
Ronald M Fairman, MD
- Professor of Surgery and Radiology
- University of Pennsylvania School of Medicine
- Section Editors
- Scott E Kasner, MD
Scott E Kasner, MD
- Section Editor — Stroke
- Professor of Neurology
- University of Pennsylvania School of Medicine
- John F Eidt, MD
John F Eidt, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor of Surgery, Texas A&M Health Science Center
- Vice Chair of Vascular Surgical Services, Baylor Heart and Vascular Hospital at Dallas
- Joseph L Mills, Sr, MD
Joseph L Mills, Sr, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor and Chief
- Division of Vascular Surgery and Endovascular Therapy
- Baylor College of Medicine
The locations most frequently affected by carotid atherosclerosis are the proximal internal carotid artery (ie, the origin) and the common carotid artery bifurcation. Progression of atheromatous plaque at the carotid bifurcation results in luminal narrowing, often accompanied by ulceration. This process can lead to ischemic stroke or transient ischemic attack from embolization, thrombosis, or hemodynamic compromise.
This topic will review the treatment of asymptomatic extracranial carotid atherosclerotic disease. The management of symptomatic extracranial carotid disease is discussed separately. (See "Management of symptomatic carotid atherosclerotic disease".)
Other aspects of carotid occlusive disease are reviewed elsewhere. (See "Pathophysiology of symptoms from carotid atherosclerosis" and "Evaluation of carotid artery stenosis" and "Carotid endarterectomy" and "Intracranial large artery atherosclerosis".)
SCOPE OF THE PROBLEM
Asymptomatic carotid atherosclerotic disease refers to the presence of atherosclerotic narrowing of the extracranial internal carotid artery in individuals without a history of recent ipsilateral carotid territory ischemic stroke or transient ischemic attack (TIA).
In contradistinction, symptomatic carotid disease is defined as focal neurologic symptoms caused by TIAs or ischemic stroke in the carotid artery territory and ipsilateral to significant carotid atherosclerotic pathology. Although there is no precise time constraint, atherosclerotic carotid disease is considered symptomatic if carotid symptoms occurred within the previous six months. Thus, remote carotid symptoms are not considered as indicative of symptomatic carotid disease.
- de Weerd M, Greving JP, Hedblad B, et al. Prevalence of asymptomatic carotid artery stenosis in the general population: an individual participant data meta-analysis. Stroke 2010; 41:1294.
- Abbott AL. Medical (nonsurgical) intervention alone is now best for prevention of stroke associated with asymptomatic severe carotid stenosis: results of a systematic review and analysis. Stroke 2009; 40:e573.
- Marquardt L, Geraghty OC, Mehta Z, Rothwell PM. Low risk of ipsilateral stroke in patients with asymptomatic carotid stenosis on best medical treatment: a prospective, population-based study. Stroke 2010; 41:e11.
- Spence JD. Management of asymptomatic carotid stenosis. Neurol Clin 2015; 33:443.
- Chimowitz MI, Weiss DG, Cohen SL, et al. Cardiac prognosis of patients with carotid stenosis and no history of coronary artery disease. Veterans Affairs Cooperative Study Group 167. Stroke 1994; 25:759.
- Goessens BM, Visseren FL, Kappelle LJ, et al. Asymptomatic carotid artery stenosis and the risk of new vascular events in patients with manifest arterial disease: the SMART study. Stroke 2007; 38:1470.
- Dodick DW, Meissner I, Meyer FB, Cloft HJ. Evaluation and management of asymptomatic carotid artery stenosis. Mayo Clin Proc 2004; 79:937.
- Pessin MS, Duncan GW, Mohr JP, Poskanzer DC. Clinical and angiographic features of carotid transient ischemic attacks. N Engl J Med 1977; 296:358.
- Mohr JP, Caplan LR, Melski JW, et al. The Harvard Cooperative Stroke Registry: a prospective registry. Neurology 1978; 28:754.
- Russo LS Jr. Carotid system transient ischemic attacks: clinical, racial, and angiographic correlations. Stroke 1981; 12:470.
- Shanik GD, Moore DJ, Leahy A, et al. Asymptomatic carotid stenosis: a benign lesion? Eur J Vasc Surg 1992; 6:10.
- Inzitari D, Eliasziw M, Gates P, et al. The causes and risk of stroke in patients with asymptomatic internal-carotid-artery stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med 2000; 342:1693.
- Goldstein LB, Adams R, Becker K, et al. Primary prevention of ischemic stroke: A statement for healthcare professionals from the Stroke Council of the American Heart Association. Stroke 2001; 32:280.
- Chambers BR, Norris JW. Outcome in patients with asymptomatic neck bruits. N Engl J Med 1986; 315:860.
- Bogousslavsky J, Despland PA, Regli F. Asymptomatic tight stenosis of the internal carotid artery: long-term prognosis. Neurology 1986; 36:861.
- Brott TG, Brown RD Jr, Meyer FB, et al. Carotid revascularization for prevention of stroke: carotid endarterectomy and carotid artery stenting. Mayo Clin Proc 2004; 79:1197.
- American College of Cardiology Foundation(ACCF), American College of Radiology(ACR), American Institute of Ultrasound in Medicine(AIUM), et al. ACCF/ACR/AIUM/ASE/ASN/ICAVL/SCAI/SCCT/SIR/SVM/SVS 2012 appropriate use criteria for peripheral vascular ultrasound and physiological testing part I: arterial ultrasound and physiological testing: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American College of Radiology, American Institute of Ultrasound in Medicine, American Society of Echocardiography, American Society of Nephrology, Intersocietal Commission for the Accreditation of Vascular Laboratories, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Interventional Radiology, Society for Vascular Medicine, and Society for Vascular Surgery. J Vasc Surg 2012; 56:e17.
- Meschia JF, Bushnell C, Boden-Albala B, et al. Guidelines for the primary prevention of stroke: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2014; 45:3754.
- Brott TG, Halperin JL, Abbara S, 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. Stroke 2011; 42:e464.
- Ricotta JJ, Aburahma A, Ascher E, et al. Updated Society for Vascular Surgery guidelines for management of extracranial carotid disease: executive summary. J Vasc Surg 2011; 54:832.
- Steppacher R, Csikesz N, Eslami M, et al. An analysis of carotid artery stenting procedures performed in New York and Florida (2005-2006): procedure indication, stroke rate, and mortality rate are equivalent for vascular surgeons and non-vascular surgeons. J Vasc Surg 2009; 49:1379.
- Eslami MH, McPhee JT, Simons JP, et al. National trends in utilization and postprocedure outcomes for carotid artery revascularization 2005 to 2007. J Vasc Surg 2011; 53:307.
- Berkowitz SA, Redberg RF. Dramatic increases in carotid stenting despite nonconclusive data. Arch Intern Med 2011; 171:1794.
- Centers for Medicare & Medicaid services. National Coverage Determination (NCD) for Percutaneous Transluminal Angioplasty (PTA) (20.7). www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=201&ncdver=9&bc=BAABAAAAAAAA& (Accessed on October 07, 2013).
- Centers for Medicare & Medicaid services. MLN Matters® Number: SE1119 Revised www.cms.gov/MLNMattersArticles/downloads/SE1119.pdf (Accessed on October 07, 2013).
- Raman G, Moorthy D, Hadar N, et al. Management strategies for asymptomatic carotid stenosis: a systematic review and meta-analysis. Ann Intern Med 2013; 158:676.
- Woo K, Garg J, Hye RJ, Dilley RB. Contemporary results of carotid endarterectomy for asymptomatic carotid stenosis. Stroke 2010; 41:975.
- Constantinou J, Jayia P, Hamilton G. Best evidence for medical therapy for carotid artery stenosis. J Vasc Surg 2013; 58:1129.
- Spence JD. Asymptomatic carotid stenosis. Circulation 2013; 127:739.
- Brett AS, Levine JD. The case against identifying carotid stenosis in asymptomatic patients. JAMA Intern Med 2014; 174:2004.
- Halliday A, Mansfield A, Marro 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.
- Spence JD, Coates V, Li H, et al. Effects of intensive medical therapy on microemboli and cardiovascular risk in asymptomatic carotid stenosis. Arch Neurol 2010; 67:180.
- Spence JD. Intensive management of risk factors for accelerated atherosclerosis: the role of multiple interventions. Curr Neurol Neurosci Rep 2007; 7:42.
- Munster AB, Franchini AJ, Qureshi MI, et al. Temporal trends in safety of carotid endarterectomy in asymptomatic patients: systematic review. Neurology 2015; 85:365.
- Chaturvedi S, Chimowitz M, Brown RD Jr, et al. The urgent need for contemporary clinical trials in patients with asymptomatic carotid stenosis. Neurology 2016; 87:2271.
- Hobson RW 2nd, Weiss DG, Fields WS, et al. Efficacy of carotid endarterectomy for asymptomatic carotid stenosis. The Veterans Affairs Cooperative Study Group. N Engl J Med 1993; 328:221.
- Endarterectomy for asymptomatic carotid artery stenosis. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. JAMA 1995; 273:1421.
- Chambers BR, Donnan GA. Carotid endarterectomy for asymptomatic carotid stenosis. Cochrane Database Syst Rev 2005; :CD001923.
- Chaturvedi S, Bruno A, Feasby T, et al. Carotid endarterectomy--an evidence-based review: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 2005; 65:794.
- Halliday A, Harrison M, Hayter E, et al. 10-year stroke prevention after successful carotid endarterectomy for asymptomatic stenosis (ACST-1): a multicentre randomised trial. Lancet 2010; 376:1074.
- Barnett HJ. Carotid endarterectomy. Lancet 2004; 363:1486.
- Rothwell PM, Goldstein LB. Carotid endarterectomy for asymptomatic carotid stenosis: asymptomatic carotid surgery trial. Stroke 2004; 35:2425.
- North American Symptomatic Carotid Endarterectomy Trial Collaborators, Barnett HJM, Taylor DW, et al. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med 1991; 325:445.
- Barnett HJ, Taylor DW, Eliasziw M, 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.
- Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST). Lancet 1998; 351:1379.
- Gorelick PB. Carotid endarterectomy : where do we draw the line? Stroke 1999; 30:1745.
- Goldstein LB, Moore WS, Robertson JT, Chaturvedi S. Complication rates for carotid endarterectomy. A call to action. Stroke 1997; 28:889.
- Barnett HJ. The inappropriate use of carotid endarterectomy. CMAJ 2004; 171:473.
- Moore WS, Vescera CL, Robertson JT, et al. Selection process for surgeons in the Asymptomatic Carotid Atherosclerosis Study. Stroke 1991; 22:1353.
- Wennberg DE, Lucas FL, Birkmeyer JD, et al. Variation in carotid endarterectomy mortality in the Medicare population: trial hospitals, volume, and patient characteristics. JAMA 1998; 279:1278.
- O'Neill L, Lanska DJ, Hartz A. Surgeon characteristics associated with mortality and morbidity following carotid endarterectomy. Neurology 2000; 55:773.
- Baker WH, Howard VJ, Howard G, Toole JF. Effect of contralateral occlusion on long-term efficacy of endarterectomy in the asymptomatic carotid atherosclerosis study (ACAS). ACAS Investigators. Stroke 2000; 31:2330.
- Kistler JP, Furie KL. Carotid endarterectomy revisited. N Engl J Med 2000; 342:1743.
- Sardar P, Chatterjee S, Aronow HD, et al. Carotid Artery Stenting Versus Endarterectomy for Stroke Prevention: A Meta-Analysis of Clinical Trials. J Am Coll Cardiol 2017; 69:2266.
- Rosenfield K, Matsumura JS, Chaturvedi S, et al. Randomized Trial of Stent versus Surgery for Asymptomatic Carotid Stenosis. N Engl J Med 2016; 374:1011.
- Brott TG, Hobson RW 2nd, Howard G, et al. Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med 2010; 363:11.
- Brott TG, Howard G, Roubin GS, et al. Long-Term Results of Stenting versus Endarterectomy for Carotid-Artery Stenosis. N Engl J Med 2016; 374:1021.
- Cohen DJ, Stolker JM, Wang K, et al. Health-related quality of life after carotid stenting versus carotid endarterectomy: results from CREST (Carotid Revascularization Endarterectomy Versus Stenting Trial). J Am Coll Cardiol 2011; 58:1557.
- Voeks JH, Howard G, Roubin GS, et al. Age and outcomes after carotid stenting and endarterectomy: the carotid revascularization endarterectomy versus stenting trial. Stroke 2011; 42:3484.
- Yadav JS, Wholey MH, Kuntz RE, et al. Protected carotid-artery stenting versus endarterectomy in high-risk patients. N Engl J Med 2004; 351:1493.
- Yadav JS. Carotid stenting in high-risk patients: design and rationale of the SAPPHIRE trial. Cleve Clin J Med 2004; 71 Suppl 1:S45.
- Gurm HS, Yadav JS, Fayad P, et al. Long-term results of carotid stenting versus endarterectomy in high-risk patients. N Engl J Med 2008; 358:1572.
- Cambria RP. Stenting for carotid-artery stenosis. N Engl J Med 2004; 351:1565.
- Thomas DJ. Protected carotid artery stenting versus endarterectomy in high-risk patients reflections from SAPPHIRE. Stroke 2005; 36:912.
- LoGerfo FW. Carotid stents: unleashed, unproven. Circulation 2007; 116:1596.
- Samuelson RM, Yamamoto J, Levy EI, et al. The argument to support broader application of extracranial carotid artery stent technology. Circulation 2007; 116:1602.
- Usman AA, Tang GL, Eskandari MK. Metaanalysis of procedural stroke and death among octogenarians: carotid stenting versus carotid endarterectomy. J Am Coll Surg 2009; 208:1124.
- Antoniou GA, Georgiadis GS, Georgakarakos EI, et al. Meta-analysis and meta-regression analysis of outcomes of carotid endarterectomy and stenting in the elderly. JAMA Surg 2013; 148:1140.
- Paraskevas KI, Spence JD, Veith FJ, Nicolaides AN. Identifying which patients with asymptomatic carotid stenosis could benefit from intervention. Stroke 2014; 45:3720.
- Yang C, Bogiatzi C, Spence JD. Risk of Stroke at the Time of Carotid Occlusion. JAMA Neurol 2015; 72:1261.
- Hirt LS. Progression rate and ipsilateral neurological events in asymptomatic carotid stenosis. Stroke 2014; 45:702.
- Roederer GO, Langlois YE, Jager KA, et al. The natural history of carotid arterial disease in asymptomatic patients with cervical bruits. Stroke 1984; 15:605.
- Autret A, Pourcelot L, Saudeau D, et al. Stroke risk in patients with carotid stenosis. Lancet 1987; 1:888.
- Norris JW, Zhu CZ. Stroke risk and critical carotid stenosis. J Neurol Neurosurg Psychiatry 1990; 53:235.
- Bock RW, Gray-Weale AC, Mock PA, et al. The natural history of asymptomatic carotid artery disease. J Vasc Surg 1993; 17:160.
- Lewis RF, Abrahamowicz M, Côté R, Battista RN. Predictive power of duplex ultrasonography in asymptomatic carotid disease. Ann Intern Med 1997; 127:13.
- Balestrini S, Lupidi F, Balucani C, et al. One-year progression of moderate asymptomatic carotid stenosis predicts the risk of vascular events. Stroke 2013; 44:792.
- Suwanwela N, Can U, Furie KL, et al. Carotid Doppler ultrasound criteria for internal carotid artery stenosis based on residual lumen diameter calculated from en bloc carotid endarterectomy specimens. Stroke 1996; 27:1965.
- Can U, Furie KL, Suwanwela N, et al. Transcranial Doppler ultrasound criteria for hemodynamically significant internal carotid artery stenosis based on residual lumen diameter calculated from en bloc endarterectomy specimens. Stroke 1997; 28:1966.
- Markus HS, King A, Shipley M, et al. Asymptomatic embolisation for prediction of stroke in the Asymptomatic Carotid Emboli Study (ACES): a prospective observational study. Lancet Neurol 2010; 9:663.
- Madani A, Beletsky V, Tamayo A, et al. High-risk asymptomatic carotid stenosis: ulceration on 3D ultrasound vs TCD microemboli. Neurology 2011; 77:744.
- Topakian R, King A, Kwon SU, et al. Ultrasonic plaque echolucency and emboli signals predict stroke in asymptomatic carotid stenosis. Neurology 2011; 77:751.
- Kakkos SK, Sabetai M, Tegos T, et al. Silent embolic infarcts on computed tomography brain scans and risk of ipsilateral hemispheric events in patients with asymptomatic internal carotid artery stenosis. J Vasc Surg 2009; 49:902.
- Singh N, Moody AR, Gladstone DJ, et al. Moderate carotid artery stenosis: MR imaging-depicted intraplaque hemorrhage predicts risk of cerebrovascular ischemic events in asymptomatic men. Radiology 2009; 252:502.
- Gupta A, Chazen JL, Hartman M, et al. Cerebrovascular reserve and stroke risk in patients with carotid stenosis or occlusion: a systematic review and meta-analysis. Stroke 2012; 43:2884.
- SCOPE OF THE PROBLEM
- Risk of stroke and cardiovascular events
- APPROACH TO MANAGEMENT
- Our approach
- Recommendations of others
- MEDICAL MANAGEMENT
- CAROTID ENDARTERECTOMY
- Endarterectomy trials
- Delay to benefit
- Perioperative complications
- Contralateral carotid stenosis or occlusion
- Stroke heterogeneity
- CAROTID STENTING
- Stenting trials
- Stenting in specific subgroups
- IDENTIFYING HIGH STROKE RISK
- Severity and progression of carotid stenosis
- Asymptomatic embolism
- Silent embolic infarcts
- Carotid plaque morphology
- Reduced cerebral blood flow reserve
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS