Management of symptomatic 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
- University of South Carolina School of Medicine Greenville
- 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 location most frequently affected by carotid atherosclerosis is the carotid bifurcation, often with extension into the proximal internal carotid artery (ie, the origin). 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 (TIA) from embolization, thrombosis, or hemodynamic compromise.
Carotid endarterectomy (CEA) is established as safe and effective by randomized controlled trials for reducing the risk of ischemic stroke in both symptomatic and asymptomatic patients with carotid artery atherosclerosis. Advances in medical management and percutaneous carotid angioplasty and stenting (CAS) are proposed alternatives to CEA that may impact the future use of surgical revascularization techniques for carotid disease.
This topic will review the treatment of symptomatic carotid atherosclerotic disease. The management of asymptomatic carotid disease is discussed separately. (See "Management of asymptomatic 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".)
DEFINITION OF SYMPTOMATIC DISEASE
Symptomatic carotid disease is defined as focal neurologic symptoms that are sudden in onset and referable to the appropriate carotid artery distribution (ipsilateral to significant carotid atherosclerotic pathology), including one or more transient ischemic attacks characterized by focal neurologic dysfunction or transient monocular blindness, or one or more minor (nondisabling) ischemic strokes . The definition is contingent on the occurrence of carotid symptoms within the previous six months [1,2]. Thus, although there is no precise time limitation, remote carotid symptoms should not be considered as indicative of "symptomatic" carotid disease.
- North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med 1991; 325:445.
- MRC European Carotid Surgery Trial: interim results for symptomatic patients with severe (70-99%) or with mild (0-29%) carotid stenosis. European Carotid Surgery Trialists' Collaborative Group. Lancet 1991; 337:1235.
- Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST). Lancet 1998; 351:1379.
- Rothwell PM, Eliasziw M, Gutnikov SA, et al. Analysis of pooled data from the randomised controlled trials of endarterectomy for symptomatic carotid stenosis. Lancet 2003; 361:107.
- North American Symptomatic Carotid Endarterectomy Trial. Methods, patient characteristics, and progress. Stroke 1991; 22:711.
- 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.
- Paciaroni M, Eliasziw M, Sharpe BL, et al. Long-term clinical and angiographic outcomes in symptomatic patients with 70% to 99% carotid artery stenosis. Stroke 2000; 31:2037.
- Alamowitch S, Eliasziw M, Algra A, et al. Risk, causes, and prevention of ischaemic stroke in elderly patients with symptomatic internal-carotid-artery stenosis. Lancet 2001; 357:1154.
- Rothwell PM, Eliasziw M, Gutnikov SA, et al. Endarterectomy for symptomatic carotid stenosis in relation to clinical subgroups and timing of surgery. Lancet 2004; 363:915.
- Paciaroni M, Eliasziw M, Kappelle LJ, et al. Medical complications associated with carotid endarterectomy. North American Symptomatic Carotid Endarterectomy Trial (NASCET). Stroke 1999; 30:1759.
- Ferguson GG, Eliasziw M, Barr HW, et al. The North American Symptomatic Carotid Endarterectomy Trial : surgical results in 1415 patients. Stroke 1999; 30:1751.
- Cunningham EJ, Bond R, Mehta Z, et al. Long-term durability of carotid endarterectomy for symptomatic stenosis and risk factors for late postoperative stroke. Stroke 2002; 33:2658.
- Rothwell PM, Gutnikov SA, Warlow CP, European Carotid Surgery Trialist's Collaboration. Reanalysis of the final results of the European Carotid Surgery Trial. Stroke 2003; 34:514.
- Rerkasem K, Rothwell PM. Carotid endarterectomy for symptomatic carotid stenosis. Cochrane Database Syst Rev 2011; :CD001081.
- 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.
- Fairhead JF, Mehta Z, Rothwell PM. Population-based study of delays in carotid imaging and surgery and the risk of recurrent stroke. Neurology 2005; 65:371.
- Ois A, Cuadrado-Godia E, Rodríguez-Campello A, et al. High risk of early neurological recurrence in symptomatic carotid stenosis. Stroke 2009; 40:2727.
- Marnane M, Ni Chroinin D, Callaly E, et al. Stroke recurrence within the time window recommended for carotid endarterectomy. Neurology 2011; 77:738.
- Johansson E, Cuadrado-Godia E, Hayden D, et al. Recurrent stroke in symptomatic carotid stenosis awaiting revascularization: A pooled analysis. Neurology 2016; 86:498.
- Rothwell PM, Eliasziw M, Gutnikov SA, et al. Sex difference in the effect of time from symptoms to surgery on benefit from carotid endarterectomy for transient ischemic attack and nondisabling stroke. Stroke 2004; 35:2855.
- Rerkasem K, Rothwell PM. Systematic review of the operative risks of carotid endarterectomy for recently symptomatic stenosis in relation to the timing of surgery. Stroke 2009; 40:e564.
- Blaisdell WF, Clauss RH, Galbraith JG, et al. Joint study of extracranial arterial occlusion. IV. A review of surgical considerations. JAMA 1969; 209:1889.
- BRUETMAN ME, FIELDS WS, CRAWFORD ES, DEBAKEY ME. CEREBRAL HEMORRHAGE IN CAROTID ARTERY SURGERY. Arch Neurol 1963; 9:458.
- Rob CG. Operation for acute completed stroke due to thrombosis of the internal carotid artery. Surgery 1969; 65:862.
- Pritz MB. Timing of carotid endarterectomy after stroke. Stroke 1997; 28:2563.
- 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.
- McPherson CM, Woo D, Cohen PL, et al. Early carotid endarterectomy for critical carotid artery stenosis after thrombolysis therapy in acute ischemic stroke in the middle cerebral artery. Stroke 2001; 32:2075.
- Bartoli MA, Squarcioni C, Nicoli F, et al. Early carotid endarterectomy after intravenous thrombolysis for acute ischaemic stroke. Eur J Vasc Endovasc Surg 2009; 37:512.
- Crozier JE, Reid J, Welch GH, et al. Early carotid endarterectomy following thrombolysis in the hyperacute treatment of stroke. Br J Surg 2011; 98:235.
- De Rango P, Brown MM, Chaturvedi S, et al. Summary of Evidence on Early Carotid Intervention for Recently Symptomatic Stenosis Based on Meta-Analysis of Current Risks. Stroke 2015; 46:3423.
- 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.
- Alamowitch S, Eliasziw M, Barnett HJ, et al. The risk and benefit of endarterectomy in women with symptomatic internal carotid artery disease. Stroke 2005; 36:27.
- Kernan WN, Viscoli CM, Brass LM, et al. The stroke prognosis instrument II (SPI-II) : A clinical prediction instrument for patients with transient ischemia and nondisabling ischemic stroke. Stroke 2000; 31:456.
- Benavente O, Eliasziw M, Streifler JY, et al. Prognosis after transient monocular blindness associated with carotid-artery stenosis. N Engl J Med 2001; 345:1084.
- Antoniou GA, Kuhan G, Sfyroeras GS, et al. Contralateral occlusion of the internal carotid artery increases the risk of patients undergoing carotid endarterectomy. J Vasc Surg 2013; 57:1134.
- Gasecki AP, Eliasziw M, Ferguson GG, et al. Long-term prognosis and effect of endarterectomy in patients with symptomatic severe carotid stenosis and contralateral carotid stenosis or occlusion: results from NASCET. North American Symptomatic Carotid Endarterectomy Trial (NASCET) Group. J Neurosurg 1995; 83:778.
- Rothwell PM, Mehta Z, Howard SC, et al. Treating individuals 3: from subgroups to individuals: general principles and the example of carotid endarterectomy. Lancet 2005; 365:256.
- Bonati LH, Lyrer P, Ederle J, et al. Percutaneous transluminal balloon angioplasty and stenting for carotid artery stenosis. Cochrane Database Syst Rev 2012; :CD000515.
- International Carotid Stenting Study investigators, Ederle J, Dobson J, et al. Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): an interim analysis of a randomised controlled trial. Lancet 2010; 375:985.
- Bonati LH, Dobson J, Featherstone RL, et al. Long-term outcomes after stenting versus endarterectomy for treatment of symptomatic carotid stenosis: the International Carotid Stenting Study (ICSS) randomised trial. Lancet 2015; 385:529.
- Bonati LH, Jongen LM, Haller S, et al. New ischaemic brain lesions on MRI after stenting or endarterectomy for symptomatic carotid stenosis: a substudy of the International Carotid Stenting Study (ICSS). Lancet Neurol 2010; 9:353.
- SPACE Collaborative Group, Ringleb PA, Allenberg J, et al. 30 day results from the SPACE trial of stent-protected angioplasty versus carotid endarterectomy in symptomatic patients: a randomised non-inferiority trial. Lancet 2006; 368:1239.
- Stingele R, Berger J, Alfke K, et al. Clinical and angiographic risk factors for stroke and death within 30 days after carotid endarterectomy and stent-protected angioplasty: a subanalysis of the SPACE study. Lancet Neurol 2008; 7:216.
- Eckstein HH, Ringleb P, Allenberg JR, et al. Results of the Stent-Protected Angioplasty versus Carotid Endarterectomy (SPACE) study to treat symptomatic stenoses at 2 years: a multinational, prospective, randomised trial. Lancet Neurol 2008; 7:893.
- Mas JL, Chatellier G, Beyssen B, et al. Endarterectomy versus stenting in patients with symptomatic severe carotid stenosis. N Engl J Med 2006; 355:1660.
- Mas JL, Trinquart L, Leys D, et al. Endarterectomy Versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis (EVA-3S) trial: results up to 4 years from a randomised, multicentre trial. Lancet Neurol 2008; 7:885.
- Furlan AJ. Carotid-artery stenting--case open or closed? N Engl J Med 2006; 355:1726.
- Qureshi AI. Carotid angioplasty and stent placement after EVA-3S trial. Stroke 2007; 38:1993.
- 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.
- Silver FL, Mackey A, Clark WM, et al. Safety of stenting and endarterectomy by symptomatic status in the Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST). Stroke 2011; 42:675.
- 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.
- Naylor AR, Bolia A, Abbott RJ, et al. Randomized study of carotid angioplasty and stenting versus carotid endarterectomy: a stopped trial. J Vasc Surg 1998; 28:326.
- Alberts MJ. Results of a multicenter prospective randomized trial of carotid artery stenting vs carotid endarterectomy [oral abstract]. Stroke 2001; 32:325.
- Brooks WH, McClure RR, Jones MR, et al. Carotid angioplasty and stenting versus carotid endarterectomy: randomized trial in a community hospital. J Am Coll Cardiol 2001; 38:1589.
- 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.
- Howard G, Roubin GS, Jansen O, et al. Association between age and risk of stroke or death from carotid endarterectomy and carotid stenting: a meta-analysis of pooled patient data from four randomised trials. Lancet 2016; 387:1305.
- Carotid Stenting Trialists' Collaboration, Bonati LH, Dobson J, et al. Short-term outcome after stenting versus endarterectomy for symptomatic carotid stenosis: a preplanned meta-analysis of individual patient data. Lancet 2010; 376:1062.
- 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.
- Attigah N, Külkens S, Deyle C, et al. Redo surgery or carotid stenting for restenosis after carotid endarterectomy: results of two different treatment strategies. Ann Vasc Surg 2010; 24:190.
- Bowser AN, Bandyk DF, Evans A, et al. Outcome of carotid stent-assisted angioplasty versus open surgical repair of recurrent carotid stenosis. J Vasc Surg 2003; 38:432.
- 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.
- Kernan WN, Ovbiagele B, Black HR, et al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2014; 45:2160.
- DEFINITION OF SYMPTOMATIC DISEASE
- CAROTID ENDARTERECTOMY
- Method of stenosis measurement
- NASCET trial
- ECST trial
- Pooled analysis
- Perioperative complication rate
- Timing of surgery
- - After mild stroke or TIA
- - After moderate to severe stroke
- - Very early or emergent CEA
- Other factors influencing benefit and risk with CEA
- - Gender
- - Retinal versus hemispheric ischemia
- - Contralateral carotid stenosis or occlusion
- Risk modeling
- CAROTID STENTING
- Randomized trials
- - ICSS
- - SPACE
- - EVA-3S
- - CREST
- - Early trials
- Effect of age
- Stenting in other subgroups
- MEDICAL MANAGEMENT
- RECOMMENDATIONS OF OTHERS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS