[Show abstract][Hide abstract] ABSTRACT: Background and purpose:
We systematically compared and appraised contemporary guidelines on management of asymptomatic and symptomatic carotid artery stenosis.
We systematically searched for guideline recommendations on carotid endarterectomy (CEA) or carotid angioplasty/stenting (CAS) published in any language between January 1, 2008, and January 28, 2015. Only the latest guideline per writing group was selected. Each guideline was analyzed independently by 2 to 6 authors to determine clinical scenarios covered, recommendations given, and scientific evidence used.
Thirty-four eligible guidelines were identified from 23 different regions/countries in 6 languages. Of 28 guidelines with asymptomatic carotid artery stenosis procedural recommendations, 24 (86%) endorsed CEA (recommended it should or may be provided) for ≈50% to 99% average-surgical-risk asymptomatic carotid artery stenosis, 17 (61%) endorsed CAS, 8 (29%) opposed CAS, and 1 (4%) endorsed medical treatment alone. For asymptomatic carotid artery stenosis patients considered high-CEA-risk because of comorbidities, vascular anatomy, or undefined reasons, CAS was endorsed in 13 guidelines (46%). Thirty-one of 33 guidelines (94%) with symptomatic carotid artery stenosis procedural recommendations endorsed CEA for patients with ≈50% to 99% average-CEA-risk symptomatic carotid artery stenosis, 19 (58%) endorsed CAS and 9 (27%) opposed CAS. For high-CEA-risk symptomatic carotid artery stenosis because of comorbidities, vascular anatomy, or undefined reasons, CAS was endorsed in 27 guidelines (82%). Guideline procedural recommendations were based only on results of trials in which patients were randomized 12 to 34 years ago, rarely reflected medical treatment improvements and often understated potential CAS hazards. Qualifying terminology summarizing recommendations or evidence lacked standardization, impeding guideline interpretation, and comparison.
This systematic review has identified many opportunities to modernize and otherwise improve carotid stenosis management guidelines.
[Show abstract][Hide abstract] ABSTRACT: Several guidelines recommend carotid endarterectomy for patients with severe asymptomatic carotid stenosis to reduce the risk of a future cerebrovascular event, as long as the perioperative stroke/death rate is <3%. Based on improvements in best medical treatment, it was argued that currently best medical treatment alone should comprise the treatment-of-choice for asymptomatic carotid stenosis patients and that no intervention is warranted in these individuals. While it is true that best medical treatment should be used for the management of all asymptomatic carotid stenosis patients, emerging evidence suggests that best medical treatment alone may not prevent disease progression and the development of symptoms in some asymptomatic carotid stenosis patient subgroups. This article analyzes the results of two recent independent studies demonstrating that medical therapy alone may not be adequate for stroke prevention in some asymptomatic carotid stenosis patient subgroups. These results suggest that besides best medical treatment, additional carotid endarterectomy should be considered for specific asymptomatic carotid stenosis patients.
[Show abstract][Hide abstract] ABSTRACT: According to the 2011, as well as the 2014 updated American Heart Association/American Stroke Association Guidelines, carotid artery stenting (CAS) is indicated as an alternative to carotid endarterectomy (CEA) for the management of symptomatic carotid patients. According to these recommendations, CAS is preferred over CEA in symptomatic patients with specific technical, anatomic or physiologic characteristics that render these individuals at "high risk" for surgery (e.g. contralateral carotid occlusion, previous neck irradiation, recurrent carotid stenosis, etc.). This article will present emerging data suggesting that most of these criteria do not comprise contraindications for CEA. In fact, CEA is associated with similar (or even better) outcomes compared with CAS in many such "high-risk" patients. Based on these results, the indications of CAS in symptomatic patients may need to be reconsidered.
Annals of Vascular Surgery 10/2014; 29(1). DOI:10.1016/j.avsg.2014.08.010 · 1.17 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Experimental models of recovery from limb ischemia are required for evaluating novel means of treating ischemia. We describe a mouse model to assess gait after inducing limb ischemia. Gait analysis was performed using a Plexiglass tube, the floor of which contained load cells. Gait was measured in 20 mice; 10 underwent ligation of the right hind limb artery and the other 10 underwent a sham operation. The gait of the animals was measured at 1, 2, and 4 weeks following the procedure. In sham-operated animals, the gait showed no measurable change. In the ligated animals, the ratio of the right fore-to-hind limb changed from 1.07 at baseline to 1.4 at day 0 (P = .001), 1.16 (P = .012 compared with control), and 1.04 (P = .37 compared with control) at weeks 2 and 4, respectively. Gait returned to normal within 4 weeks of induction of ischemia. This model may be helpful in testing potential novel therapies.
[Show abstract][Hide abstract] ABSTRACT: Dear Editor, Luo et al. (2014) reported that the combination of atorvastatin plus ezetimibe de-creased carotid intima media thickness (cIMT) significantly more than atorvastatin mono-therapy. We would like to add a few comments. The ENHANCE trial (Kastelein et al., 2008) did not compare the effect of atorvastatin plus ezetimibe versus atorvastatin monotherapy on cIMT, as mentioned by Luo et al. (2014). The statin used was simvastatin. As Luo et al. (2014) state, the cIMT in ENHANCE was set too low and could not be reduced further. There are other deficiencies in the ENHANCE trial; these are discussed by us in Paraskevas et al. (2011). Briefly, the latter article also comments on other trials that show that ezetimibe, used together with a statin, decreases cIMT. Furthermore, this article also considers evidence that atorvas-tatin 80 mg/day did not reduce the cIMT when compared with placebo (CASHMERE study), probably because the cIMT was too low (virtually identical to that in ENHANCE). How-ever, ENHANCE produced useful information. The C-reactive protein (CRP) level dropped significantly more in the simvastatin plus ezetimibe group compared with the simvastatin monotherapy group (Kastelein et al., 2008). The same pattern was reported by Luo et al. (2014), in which the fall in high sensitivity CRP (hsCRP) level was significantly greater in the atorvastatin plus ezetimibe group compared with the atorvastatin monotherapy group. Indeed as Luo et al. (2014) state, doubling the dose of a statin only results in about 6% further fall in low density lipoprotein cholesterol (LDL-C) levels. A meta-analysis by our group showed that adding ezetimibe to a statin results in an average 23.6% fall in LDL-C levels compared with statin monotherapy (Mikhailidis et al., 2007). This meta-analysis also showed that the addition of ezetimibe to a statin increased the fall in CRP levels. Another meta-analysis showed that adding ezetimibe to a statin is more effective than doubling the dose of the statin (Mikhailidis et al., 2011). Ezetimibe has several potentially useful actions other than altering the lipid pro-file (Lioudaki et al., 2011). However, it is difficult to assess the contribution of these effects on vascular risk. Other researchers, as well as our group, have observed that high triglyceride levels fall to a greater extent than low levels when ezetimibe is added to a statin (Gazi et al., 2007; Fras and Mikhailidis, 2008; Migdalis et al., 2009; Shigematsu et al., 2012). Therefore, it would be useful to know if the fall in triglyceride levels was greater in the atorvastatin plus ezetimibe group compared with the atorvastatin monotherapy group if only triglyceride levels ≥1.7 or ≥2.0 mM are considered in the Luo et al. (2014) study. Also, it would be interesting to know if Luo et al. (2014) performed kidney function tests, since there is some evidence that adding ezetimibe to a statin will improve that variable (Gazi et al., 2007; Migdalis et al., 2009). The debate about the evidence supporting the use of ezetimibe to reduce the risk of vascular events continues (Gouni-Berthold et al., 2012). However, the findings of Luo et al. (2014) further support the conclusion that the cIMT results of the ENHANCE trial should not be included in this debate. Secondly, it is relevant that several guidelines mention that the use of ezetimibe is appropriate if LDL-C targets are not reached by statin monotherapy (Catapano et al., 2011; Perk et al., 2012; Teramoto et al., 2013; Anderson et al., 2013; Wanner and Tonelli, 2014; IAS Position Paper, 2014). The recent dyslipidemia guidelines issued by the American College of Cardiology/American Heart Association (Stone et al., 2013) focus on statins and only briefly mentions other lipid lowering options (Mikhailidis et al., 2014).
[Show abstract][Hide abstract] ABSTRACT: With increasing carotid artery stenting (CAS) expertise and improved CAS equipment, recent trials have demonstrated better results for CAS compared with earlier studies. As a result, it may be argued that CAS is currently non-inferior to carotid endarterectomy (CEA), at least in some patient subgroups. Consequently, there have been recent calls for extending CAS indications to include average surgical risk patients with symptomatic or asymptomatic carotid stenosis. However, CAS remains a less cost-effective option than CEA. Opening the floodgates to unrestricted CAS for both symptomatic and asymptomatic carotid patients would have considerable cost implications for any health system. Appropriate patient selection and keeping to the indications are crucial to optimize CAS outcomes.
Expert Review of Cardiovascular Therapy 07/2014; 12(7):783-6. DOI:10.1586/14779072.2014.921118
[Show abstract][Hide abstract] ABSTRACT: The optimal management of patients with symptomatic and asymptomatic carotid artery stenosis remains a subject of extensive debate. Several international societies and associations have published guidelines for the management of carotid patients. Although these recommendations are based on the same randomized trials, differences in interpretation of available knowledge have often led to different (or even conflicting) recommendations. This special report summarizes the current evidence-based optimal management of patients with symptomatic and asymptomatic carotid stenosis and compares key international guidelines. Finally, issues requiring further research are identified and discussed.
Expert Review of Cardiovascular Therapy 03/2014; 12(4). DOI:10.1586/14779072.2014.893826