Article

Management Strategies for Asymptomatic Carotid Stenosis A Systematic Review and Meta-analysis

Brown University, Providence, Rhode Island, United States
Annals of internal medicine (Impact Factor: 17.81). 05/2013; 158(9):676-85. DOI: 10.7326/0003-4819-158-9-201305070-00007
Source: PubMed

ABSTRACT

Adults with asymptomatic carotid artery stenosis are at increased risk for ipsilateral carotid territory ischemic stroke.
To examine comparative evidence on management strategies for asymptomatic carotid stenosis and the incidence of ipsilateral stroke with medical therapy alone.
MEDLINE, Cochrane Central Register of Controlled Trials, U.S. Food and Drug Administration documents, and review of references through 31 December 2012.
Randomized, controlled trials (RCTs) and prospective or retrospective nonrandomized, comparative studies of medical therapy alone, carotid endarterectomy (CEA) plus medical therapy, or carotid artery stenting (CAS) plus medical therapy for adults with asymptomatic carotid stenosis, as well as single-group prospective cohort studies of medical therapy, were reviewed.
Two investigators extracted information on study and population characteristics, results, and risk of bias.
Forty-seven studies in 56 publications were eligible. The RCTs comparing CAS and CEA were clinically heterogeneous; 1 RCT reported more but not statistically significant ipsilateral stroke events (including any periprocedural stroke) in CAS compared with CEA, whereas another RCT, in a population at high surgical risk for CEA, did not. Three RCTs showed that CEA reduced the risk for ipsilateral stroke (including any periprocedural stroke) compared with medical therapy alone, but these results may no longer be applicable to contemporary clinical practice. No RCT compared CAS versus medical therapy alone. The summary incidence of ipsilateral stroke across 26 cohorts receiving medical therapy alone was 1.68% per year.
Studies defined asymptomatic status heterogeneously. Participants in RCTs did not receive best-available medical therapy.
Future RCTs of asymptomatic carotid artery stenosis should explore whether revascularization interventions provide benefit to patients treated by best-available medical therapy.
Agency for Healthcare Research and Quality.

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    • "The risk of asymptomatic stenosis progression rises over time, depending on the presence of additional risk factors such as smoking, arterial hypertension, DM, the level of stenosis, the composition of the plaque and contralateral impairment of the ICA [25]. In short-term monitoring, the risk of ipsilateral IS in patients with asymptomatic ICA stenosis ranges between 1% and 3%, depending on the seriousness of the stenosis and the studied population [24]. As there have been significant advances in conservative and invasive treatment, no valid data is available right now that assesses the real risk of asymptomatic ICA stenosis comparing these two different management strategies. "
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