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SPREAD V Ed. | |
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Surgical treatment |
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| S 13-1 | The benefit of carotid endarterectomy over medical therapy is small in symptomatic patients with 50%-69% stenosis (NNT=22 to prevent one ipsilateral stroke, non significant NNT to prevent disabling stroke and death) and noticeable for 70%-99% stenosis (NNT=6 and 14 respectively), provided that there in no near-occlusions. The benefit from endarterectomy is marginal in patients with carotid near-occlusion. The benefit of endarterectomy is still greater in patients with a high risk score according to the current models (NNT=3) and questionable in patients with low risk score (NNT=100). | ||||||||||
| R 13.1 Grade A |
Carotid endarterectomy is recommended for patients with symptomatic stenosis equal to or greater than 70% (NASCET criteria). | ||||||||||
| R 13.2 Grade A |
Carotid endarterectomy is not recommended for patients with symptomatic stenosis less than 50% (NASCET criteria). | ||||||||||
| R 13.3 Grade A |
Carotid endarterectomy is recommended for patients with symptomatic stenosis of 50%-69% (NASCET criteria) – even though the benefit vs. medical therapy is small, at least during the first years of follow-up while increasing in the subsequent years – in particular among patients considered at high risk, such as those recent ischaemia, with hemispheric and not ocular symptoms, with complicated plaques, elderly, males, non diabetics. | ||||||||||
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R 13.4 Grade A |
In case of stenosis greater than 50% (NASCET criteria) and TIA or minor stroke, early - i.e. within the two weeks from the event - endarterectomy is recommended. | ||||||||||
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R 13.5 *GPP |
By convention derived from clinical trials, a carotid stenosis is defined as "symptomatic" when the last ischemic cerebral or ocular event occurred in the previous 6 months. Based on recent reassessments of the same studies, this interval should be reduced to not more than 3 months. | ||||||||||
| S 13-2 | The benefit from carotid endarterectomy has been determined in patients with asymptomatic stenosis. Nevertheless, systematic reviews ought to identify the subsets of patients at risk of ipsilateral stroke and expected to have a greater benefit from carotid surgery, taking into account that the benefit is evident and increasing only from the third year after the procedure. | ||||||||||
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R 13.6 Grade A |
Carotid endarterectomy is recommended for patients with asymptomatic stenosis greater than 60% (NASCET criteria) only in centres with very low (at least less than 3%) perioperative (within 1 month) complication rate. The benefit, expressed as absolute risk reduction, is small (1% per year) and increases with the years of follow-up. | ||||||||||
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R 13.7 Grade D |
In patients who are candidates to carotid endarterectomy, coronary angiography is recommended when there is clinical or non-invasive instrumental evidence of severe coronary artery disease. | ||||||||||
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R 13.8 Grade D |
In patients who are candidate to carotid
and coronary re-vascularization, it is recommended to
give priority to the clinically most affected district. If carotid revascularization is planned first, then stenting is recommended in presence of a severe symptomatic coronary disease, whilst endarterectomy is recommended in presence of a moderate coronary disease. |
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R 13.9 *GPP |
In patients with concurrent carotid and coronary disease, a multi-disciplinary approach (cardiological, neurological, vascular/endovascular surgical, cardiosurgical, anaesthesiological) is recommended in order to select which district should take precedence and which carotid revascularization (endarterectomy or stenting) is most appropriate. | ||||||||||
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R 13.10 Grade C |
The timing of carotid surgery in patients with symptomatic carotid stenosis should be selected based on the clinical profile of the event as well as the brain CT or MRI. | ||||||||||
| R 13.11 Grade C | Carotid endarterectomy is not recommended for patients with disabling stroke. | ||||||||||
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R 13.12 Grade B |
 Carotid Doppler ultrasonography,
if validated and therefore of controlled reliability,
is recommended as a
first-choice investigation to select possible candidates to carotid endarterectomy. |
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R 13.13 Grade B |
Carotid Doppler ultrasonography,
if validated,
is recommended as the sole
preoperative measurement of carotid stenosis in patient with TIA
or minor stroke during the last week and with carotid stenosis
greater than 70% (NASCET criteria). In addition to Doppler sonography also an angio MRI with contrast media or, if not available, an angio-CT as long as validated, should be performed in patients:
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| S 13-3 | Available data support, with some caution, the reliability of non-invasive tests (carotid echo-Doppler, angio-CT and angio MRI with contrast media) to diagnose a carotid stenosis between 70% and 99%, as long as used by experts in carotid imaging. There are insufficient data, and funther confirmatory studies are required, for stenoses between 50% and 69%. | ||||||||||
| S 13-4 | Studies comparing more than one non-invasive technique with traditional angiography are missing. Angio MRI with contrast media appears to have a better sensibility and specificity profile than echo-Doppler, angio-CT and angio MRI (which are substantially superposed). However, the external validity of these results, taken from selected studies, may be modest. Indeed, the applicability of non-invasive techniques varies across centres in terms of available instruments and of operators' expertise. It may therefore be hypothesised that in specific centres a different technique than angio MRI with contrast media offers greater guarantee of sensibility and specificity. | ||||||||||
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R 13.14 ®GPP |
Conventional angiography should be limited to cases where Doppler ultrasonography and angio MRI with contrast media or CT angiography yield discordant results or if they are not feasible and ultrasonography results unreliable | ||||||||||
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R 13.15 Grade D |
Intra-operative monitoring of cerebral functions by means of reliable techniques (EEG, Somatosensory Evoked Potentials) is recommended during general anaesthesia. | ||||||||||
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R 13.16 Grade D |
Loco-regional anaesthesia is recommended in performing endarterectomy because it allows a more reliable monitoring of cerebral functions and it is associated with a lower perioperative risk of lethal and nonlethal vascular events and of respiratory complications, compared with general anaesthesia. | ||||||||||
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R 13.17 Grade D |
Transcranial echo-Doppler of controlled reliability is complementary for the perioperative cerebral monitoring during carotid surgery. | ||||||||||
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R 13.18 Grade D |
Temporary selective intraluminal shunting is recommended for cerebral protection during carotid endarterectomy. | ||||||||||
| S 13-5 | In spite of a
trend, in randomised studies, in favour of carotid patching in
lowering the incidence of perioperative stroke and death, thrombosis
or restenosis, no conclusive data are available yet. Further evidence is needed from randomised trials comparing primary closure with routine patching and with selective patching, which is currently the most frequently used. To date, no indication can be given as to the material most suitable for patching, even though synthetic material is currently preferred over the biological one. |
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R 13.19 Grade A |
Being the current evidence still insufficient, it is not recommended to systematically replace endarterectomy with endovascular procedures for the elective correction of carotid stenosis. | ||||||||||
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R 13.20 Grade B |
Carotid
stenting, if performed with adequate procedural quality levels and
adequate cerebral protection - unless contraindicated in the
individual patient - is recommended
in presence of severe vascular and/or cardiac comorbidities as well
as in presence of special conditions such as contralateral laryngeal
nerve palsy, cranial stenosis of the internal carotid or common carotid lesions below the clavicle. By convention, severe cardiac comorbidities include:
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R 13.21 |
Carotid stenting, if performed with adequate procedural quality levels and adequate cerebral protection - unless contraindicated in the individual patient - is recommended in selected cases, such as: restenosis, post-irradiation stenosis , previous tracheostomy, rigid or "hostile" neck, as well as - thoogh with modest benefit over endarterectomy, in case of contralateral internal carotid occlusion. | ||||||||||
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R 13.22 Grade C |
Carotid stenting is not recommended when the presence of endoluminal thrombotic or thromboembolic material is suspected, and/on in presence of important calcifications or of markedly tortuous supra-aortic vessels, bovine aortic arch, important peripheral arterial comorbidity of the access point. | ||||||||||
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R 13.23 ®GPP |
Whenever
the indication to carotid re-vascularization in not definite in
favour of endarterectomy or stenting, the following options
are particularly recommended:
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| S 13-6 | Advanced age (>80 years) alone, unless associated with relevant comorbidities, does not justify in itself an indication to carotid stenting. From the analysis of retrospective studies it appears instead that the risk-to-benefit ratio among these patients is more in favour of endarterectomy than of stenting and more for the symptomatic (the prevalence of which is markedly greater than among younger patients) rather then the asymptomatic stenosis. For this last, the risk-to-benefit ratio becomes the more in favour of medical rather than surgical therapy, the more advanced is the age. | ||||||||||
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R 13.24 Grade A |
Both conventional and eversion carotid endarterectomy are recommended for patients with carotid stenosis, provided that they are performed in centres with a perioperative complication rate (all strokes and death) of less than 3%. | ||||||||||
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R 13.25 Grade B |
Centres performing carotid endarterectomy
should assess and disclose their own perioperative
complication rate (all strokes and death), since this could have
an impact on decision about carotid surgery especially in patients
with asymptomatic carotid stenosis. |
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R 13.15 Grade D |
During carotid endarterectomy, the intraoperative
assessment of defects is recommended
for possible repair and
quality control. The intraoperative control is associated to a significant reduction of peri- and post-operative complications including re-stenosis and long-term recurrence of stroke. |
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R 13.27 Grade A |
The antiplatelet therapy is recommended before and after surgical correction of carotid stenosis, unless it is contra-indicated. | ||||||||||
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R 13.28 Grade D |
In case of restenosis or recurrent restenosis of high-grade and responsible of definitely correlated neurological symptoms, surgical correction is recommended. | ||||||||||
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R 13.29 Grade D |
For the follow-up after carotid surgery. an early ultrasonographic control is recommended within 3 months from intervention then, in absence of significant homo- or contralateral evolution, after 6 months, 1 year and every year thereafter. |
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