Neurointervention.  2023 Mar;18(1):9-22. 10.5469/neuroint.2023.00031.

Carotid Artery Stenting for Asymptomatic Carotid Stenosis: What We Need to Know for Treatment Decision

• Baek JH

• KMID: 2539942
• DOI: http://doi.org/10.5469/neuroint.2023.00031

Abstract

A clinical decision on the treatment of asymptomatic carotid stenosis is challenging, unlike symptomatic carotid stenosis. Carotid artery stenting (CAS) has been recommended as an alternative to carotid endarterectomy (CEA) based on the finding that the efficacy and safety of CAS were comparable to CEA in randomized trials. However, in some countries, CAS is often performed more frequently than CEA for asymptomatic carotid stenosis. Moreover, it has been recently reported that CAS is not superior to the best medical treatment in asymptomatic carotid stenosis. Due to these recent changes, the role of CAS in asymptomatic carotid stenosis should be revisited. When determining the treatment for asymptomatic carotid stenosis, one should consider several clinical factors including stenosis degree, patient life expectancy, stroke risk by medical treatment, availability of a vascular surgeon, high risk for CEA or CAS, and insurance coverage. This review aimed to present and pragmatically organize the information that is necessary for a clinical decision on CAS in asymptomatic carotid stenosis. In conclusion, although the traditional benefit of CAS is being revisited recently, it seems too early to conclude that CAS is no longer beneficial under intense and systemic medical treatment. Instead, a treatment strategy with CAS should evolve to select eligible or medically high-risk patients more precisely.

Keyword

Carotid artery stenting; Asymptomatic carotid stenosis; Stroke

Reference

1. Naylor AR, Ricco JB, de Borst GJ, Debus S, de Haro J, Halliday A, et al. Editor’s choice - management of atherosclerotic carotid and vertebral artery disease: 2017 clinical practice guidelines of the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg. 2018; 55:3–81.

2. Paraskevas KI, Mikhailidis DP, Antignani PL, Baradaran H, Bokkers RPH, Cambria RP, et al. Optimal management of asymptomatic carotid stenosis in 2021: the jury is still out. An international, multispecialty, expert review and position statement. J Stroke Cerebrovasc Dis. 2022; 31:106182.

3. Hackam DG. Optimal medical management of asymptomatic carotid stenosis. Stroke. 2021; 52:2191–2198.

4. Messas E, Goudot G, Halliday A, Sitruk J, Mirault T, Khider L, et al. Management of carotid stenosis for primary and secondary prevention of stroke: state-of-the-art 2020: a critical review. Eur Heart J Suppl. 2020; 22(Suppl M):M35–M42.

5. Endarterectomy for asymptomatic carotid artery stenosis. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. JAMA. 1995; 273:1421–1428.

6. Halliday A. Treatment of asymptomatic carotid artery stenosis. Lancet Neurol. 2022; 21:858–859.

7. White CJ, Brott TG, Gray WA, Heck D, Jovin T, Lyden SP, et al. Carotid artery stenting: JACC state-of-the-art review. J Am Coll Cardiol. 2022; 80:155–170.

8. Seo KD, Lee KY, Suh SH. Comparison of long term prognosis between carotid endarterectomy versus stenting; a Korean population-based study using National Insurance data. Neurointervention. 2019; 14:82–90.

9. Gurm HS, Yadav JS, Fayad P, Katzen BT, Mishkel GJ, Bajwa TK, SAPPHIRE Investigators, et al. Long-term results of carotid stenting versus endarterectomy in high-risk patients. N Engl J Med. 2008; 358:1572–1579.

10. Brott TG, Hobson RW 2nd, Howard G, Roubin GS, Clark WM, Brooks W, CREST Investigators, et al. Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med. 2010; 363:11–23.

11. Rosenfield K, Matsumura JS, Chaturvedi S, Riles T, Ansel GM, Metzger DC, ACT I Investigators, et al. Randomized trial of stent versus surgery for asymptomatic carotid stenosis. N Engl J Med. 2016; 374:1011–1020.

12. Halliday A, Bulbulia R, Bonati LH, Chester J, Cradduck-Bamford A, Peto R, ACST-2 Collaborative Group, et al. Second asymptomatic carotid surgery trial (ACST-2): a randomised comparison of carotid artery stenting versus carotid endarterectomy. Lancet. 2021; 398:1065–1073.

13. Reiff T, Eckstein HH, Mansmann U, Jansen O, Fraedrich G, Mudra H, SPACE-2 Investigators, et al. 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 trial. Lancet Neurol. 2022; 21:877–888.

14. Wang J, Bai X, Wang T, Dmytriw AA, Patel AB, Jiao L. Carotid stenting versus endarterectomy for asymptomatic carotid artery stenosis: a systematic review and meta-analysis. Stroke. 2022; 53:3047–3054.

15. Reiff T, Eckstein HH, Amiri H, Hacke W, Ringleb PA; SPACE-2 Study Group. Modification of SPACE-2 study design. Int J Stroke. 2014; 9:E12–E13.

16. Kim HW, Regenhardt RW, D’Amato SA, Nahhas MI, Dmytriw AA, Hirsch JA, et al. Asymptomatic carotid artery stenosis: a summary of current state of evidence for revascularization and emerging high-risk features. [published online ahead of print Sep 9, 2022]. J Neurointerv Surg. 2022.

17. Howard VJ, Meschia JF, Lal BK, Turan TN, Roubin GS, Brown RD Jr, CREST-2 Study Investigators, et al. Carotid revascularization and medical management for asymptomatic carotid stenosis: protocol of the CREST-2 clinical trials. Int J Stroke. 2017; 12:770–778.

18. Biller J, Feinberg WM, Castaldo JE, Whittemore AD, Harbaugh RE, Dempsey RJ, et al. Guidelines for carotid endarterectomy: a statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke. 1998; 29:554–562.

19. Gorelick PB, Sacco RL, Smith DB, Alberts M, Mustone-Alexander L, Rader D, et al. Prevention of a first stroke: a review of guidelines and a multidisciplinary consensus statement from the National Stroke Association. JAMA. 1999; 281:1112–1120.

20. Goldstein LB, Adams R, Alberts MJ, Appel LJ, Brass LM, Bushnell CD, et al. Primary prevention of ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council: cosponsored by the Atherosclerotic Peripheral Vascular Disease Interdisciplinary Working Group; Cardiovascular Nursing Council; Clinical Cardiology Council; Nutrition, Physical Activity, and Metabolism Council; and the Quality of Care and Outcomes Research Interdisciplinary Working Group: the American Academy of Neurology affirms the value of this guideline. Stroke. 2006; 37:1583–1633.

21. Hobson RW 2nd, Mackey WC, Ascher E, Murad MH, Calligaro KD, Comerota AJ, Society for Vascular Surgery, et al. Management of atherosclerotic carotid artery disease: clinical practice guidelines of the Society for Vascular Surgery. J Vasc Surg. 2008; 48:480–486.

22. Liapis CD, Bell PR, Mikhailidis D, Sivenius J, Nicolaides A, Fernandes e Fernandes J, et al. ESVS Guidelines Collaborators. ESVS guidelines. Invasive treatment for carotid stenosis: indications, techniques. Eur J Vasc Endovasc Surg. 2009; 37(4 Suppl):1–19.

23. Goldstein LB, Bushnell CD, Adams RJ, Appel LJ, Braun LT, Chaturvedi S, et al. Guidelines for the primary prevention of stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2011; 42:517–584.

24. European Stroke Organisation, Tendera M, Aboyans V, Bartelink ML, Baumgartner I, Clément D, Collet JP, et al. ESC guidelines on the diagnosis and treatment of peripheral artery diseases: document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries: the Task Force on the Diagnosis and Treatment of Peripheral Artery Diseases of the European Society of Cardiology (ESC). Eur Heart J. 2011; 32:2851–2906.

25. Ricotta JJ, Aburahma A, Ascher E, Eskandari M, Faries P, Lal BK; Society for Vascular Surgery. Updated Society for Vascular Surgery guidelines for management of extracranial carotid disease. J Vasc Surg. 2011; 54:e1–e31.

26. Meschia JF, Bushnell C, Boden-Albala B, Braun LT, Bravata DM, Chaturvedi S, et al. Guidelines for the primary prevention of stroke: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014; 45:3754–3832.

27. Eckstein HH, Kühnl A, Berkefeld J, Lawall H, Storck M, Sander D. Diagnosis, treatment and follow-up in extracranial carotid stenosis. Dtsch Arztebl Int. 2020; 117:801–807.

28. AbuRahma AF, Avgerinos ED, Chang RW, Darling RC 3rd, Duncan AA, Forbes TL, et al. The Society for Vascular Surgery implementation document for management of extracranial cerebrovascular disease. J Vasc Surg. 2022; 75(1S):26S–98S.

29. Bonati LH, Kakkos S, Berkefeld J, de Borst GJ, Bulbulia R, Halliday A, et al. European Stroke Organisation guideline on endarterectomy and stenting for carotid artery stenosis. Eur Stroke J. 2021; 6:I–XLVII.

30. Hadar N, Raman G, Moorthy D, O’Donnell TF, Thaler DE, Feldmann E, et al. Asymptomatic carotid artery stenosis treated with medical therapy alone: temporal trends and implications for risk assessment and the design of future studies. Cerebrovasc Dis. 2014; 38:163–173.

31. Hirt LS. Progression rate and ipsilateral neurological events in asymptomatic carotid stenosis. Stroke. 2014; 45:702–706.

32. Kakkos SK, Nicolaides AN, Charalambous I, Thomas D, Giannopoulos A, Naylor AR, Asymptomatic Carotid Stenosis and Risk of Stroke (ACSRS) Study Group, et al. Predictors and clinical significance of progression or regression of asymptomatic carotid stenosis. J Vasc Surg. 2014; 59:956–967.e1.

33. Nicolaides AN, Kakkos SK, Kyriacou E, Griffin M, Sabetai M, Thomas DJ, Asymptomatic Carotid Stenosis and Risk of Stroke (ACSRS) Study Group, et al. Asymptomatic internal carotid artery stenosis and cerebrovascular risk stratification. J Vasc Surg. 2010; 52:1486–1496.e1-5.

34. Brinjikji W, Huston J 3rd, Rabinstein AA, Kim GM, Lerman A, Lanzino G. Contemporary carotid imaging: from degree of stenosis to plaque vulnerability. J Neurosurg. 2016; 124:27–42.

35. Gupta A, Kesavabhotla K, Baradaran H, Kamel H, Pandya A, Giambrone AE, et al. Plaque echolucency and stroke risk in asymptomatic carotid stenosis: a systematic review and meta-analysis. Stroke. 2015; 46:91–97.

36. Gupta A, Baradaran H, Schweitzer AD, Kamel H, Pandya A, Delgado D, et al. Carotid plaque MRI and stroke risk: a systematic review and meta-analysis. Stroke. 2013; 44:3071–3077.

37. Kakkos SK, Griffin MB, Nicolaides AN, Kyriacou E, Sabetai MM, Tegos T, Asymptomatic Carotid Stenosis and Risk of Stroke (ACSRS) Study Group, et al. The size of juxtaluminal hypoechoic area in ultrasound images of asymptomatic carotid plaques predicts the occurrence of stroke. J Vasc Surg. 2013; 57:609–618.e1. discussion 617-618.

38. Kakkos SK, Sabetai M, Tegos T, Stevens J, Thomas D, Griffin M, Asymptomatic Carotid Stenosis and Risk of Stroke (ACSRS) Study Group, 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; 49:902–909.

39. Nicolaides AN, Kakkos SK, Griffin M, Sabetai M, Dhanjil S, Tegos T, Asymptomatic Carotid Stenosis and Risk of Stroke (ACSRS) Study Group, et al. Severity of asymptomatic carotid stenosis and risk of ipsilateral hemispheric ischaemic events: results from the ACSRS study. Eur J Vasc Endovasc Surg. 2005; 30:275–284.

40. King A, Serena J, Bornstein NM, Markus HS; ACES Investigators. Does impaired cerebrovascular reactivity predict stroke risk in asymptomatic carotid stenosis? A prospective substudy of the asymptomatic carotid emboli study. Stroke. 2011; 42:1550–1555.

41. Markus HS, King A, Shipley M, Topakian R, Cullinane M, Reihill S, et al. Asymptomatic embolisation for prediction of stroke in the Asymptomatic Carotid Emboli Study (ACES): a prospective observational study. Lancet Neurol. 2010; 9:663–671.

42. Topakian R, King A, Kwon SU, Schaafsma A, Shipley M, Markus HS; ACES Investigators. Ultrasonic plaque echolucency and emboli signals predict stroke in asymptomatic carotid stenosis. Neurology. 2011; 77:751–758.

43. Maatz W, Köhler J, Botsios S, John V, Walterbusch G. Risk of stroke for carotid endarterectomy patients with contralateral carotid occlusion. Ann Vasc Surg. 2008; 22:45–51.

44. AbuRahma AF, Robinson P, Holt SM, Herzog TA, Mowery NT. Perioperative and late stroke rates of carotid endarterectomy contralateral to carotid artery occlusion: results from a randomized trial. Stroke. 2000; 31:1566–1571.

45. Moore WS, Popma JJ, Roubin GS, Voeks JH, Cutlip DE, Jones M, CREST Investigators, et al. Carotid angiographic characteristics in the CREST trial were major contributors to periprocedural stroke and death differences between carotid artery stenting and carotid endarterectomy. J Vasc Surg. 2016; 63:851–857, 858.e1.

46. Wyers MC, Powell RJ, Fillinger MF, Nolan BW, Cronenwett JL. The value of 3D-CT angiographic assessment prior to carotid stenting. J Vasc Surg. 2009; 49:614–622.

47. Chang CK, Huded CP, Nolan BW, Powell RJ. Prevalence and clinical significance of stent fracture and deformation following carotid artery stenting. J Vasc Surg. 2011; 54:685–690.

48. Howard G, Roubin GS, Jansen O, Hendrikse J, Halliday A, Fraedrich G, Carotid Stenting Trialists’ Collaboration, 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; 387:1305–1311.

49. Halliday A, Mansfield A, Marro J, Peto C, Peto R, Potter J, MRC Asymptomatic Carotid Surgery Trial (ACST) Collaborative Group, et al. Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomised controlled trial. Lancet. 2004; 363:1491–1502.

50. Hamdan AD, Pomposelli FB Jr, Gibbons GW, Campbell DR, LoGerfo FW. Renal insufficiency and altered postoperative risk in carotid endarterectomy. J Vasc Surg. 1999; 29:1006–1011.