European Stroke Organisation guideline on endarterectomy and stenting for carotid artery stenosis

Leo H Bonati, Stavros Kakkos, Joachim Berkefeld, Gert J de Borst, Richard Bulbulia, Alison Halliday, Isabelle van Herzeele, Igor Koncar, Dominick Jh McCabe, Avtar Lal, Jean-Baptiste Ricco, Peter Ringleb, Martin Taylor-Rowan, Hans-Henning Eckstein, Leo H Bonati, Stavros Kakkos, Joachim Berkefeld, Gert J de Borst, Richard Bulbulia, Alison Halliday, Isabelle van Herzeele, Igor Koncar, Dominick Jh McCabe, Avtar Lal, Jean-Baptiste Ricco, Peter Ringleb, Martin Taylor-Rowan, Hans-Henning Eckstein

Abstract

Atherosclerotic stenosis of the internal carotid artery is an important cause of stroke. The aim of this guideline is to analyse the evidence pertaining to medical, surgical and endovascular treatment of patients with carotid stenosis. These guidelines were developed based on the ESO standard operating procedure and followed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. The working group identified relevant questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and wrote recommendations. Based on moderate quality evidence, we recommend carotid endarterectomy (CEA) in patients with ≥60-99% asymptomatic carotid stenosis considered to be at increased risk of stroke on best medical treatment (BMT) alone. We also recommend CEA for patients with ≥70-99% symptomatic stenosis, and we suggest CEA for patients with 50-69% symptomatic stenosis. Based on high quality evidence, we recommend CEA should be performed early, ideally within two weeks of the last retinal or cerebral ischaemic event in patients with ≥50-99% symptomatic stenosis. Based on low quality evidence, carotid artery stenting (CAS) may be considered in patients < 70 years old with symptomatic ≥50-99% carotid stenosis. Several randomised trials supporting these recommendations were started decades ago, and BMT, CEA and CAS have evolved since. The results of another large trial comparing outcomes after CAS versus CEA in patients with asymptomatic stenosis are anticipated in the near future. Further trials are needed to reassess the benefits of carotid revascularisation in combination with modern BMT in subgroups of patients with carotid stenosis.

Keywords: Carotid stenosis; endarterectomy; medical therapy; stenting; stroke; transient ischaemic attack.

© European Stroke Organisation 2021.

Figures

Figure 1.1.
Figure 1.1.
Long-term risk of ipsilateral stroke, including peri-procedural stroke in any territory or peri-procedural death in endarterectomy versus medical therapy for asymptomatic carotid stenosis.
Figure 1.2.
Figure 1.2.
Long-term risk of stroke in any territory, including peri-procedural death in endarterectomy versus medical therapy for asymptomatic carotid stenosis.
Figure 1.2.1.
Figure 1.2.1.
Long-term risk of stroke in any territory, including peri-procedural death in endarterectomy versus medical therapy for asymptomatic carotid stenosis. Subgroup: Sex.
Figure 1.2.2.
Figure 1.2.2.
Long-term risk of stroke in any territory, including peri-procedural death in endarterectomy versus medical therapy for asymptomatic carotid stenosis. Subgroup: Age.
Figure 1.2.3.
Figure 1.2.3.
Long-term risk of stroke in any territory, including peri-procedural death in endarterectomy versus medical therapy for asymptomatic carotid stenosis. Subgroup: Severity of carotid stenosis.
Figure 1.3.
Figure 1.3.
Long-term risk of major stroke, including peri-procedural death in endarterectomy versus medical therapy for asymptomatic carotid stenosis.
Figure 1.4.
Figure 1.4.
Long-term risk of death in endarterectomy versus medical therapy for asymptomatic carotid stenosis.
Figure 2.1.
Figure 2.1.
Long-term risk of ipsilateral stroke, including peri-procedural stroke in any territory or peri-procedural death in stenting versus medical therapy for asymptomatic carotid stenosis.
Figure 2.2.
Figure 2.2.
Long-term risk of stroke in any territory, including peri-procedural death in stenting versus medical therapy for asymptomatic carotid stenosis.
Figure 2.3.
Figure 2.3.
Long-term risk of major stroke, including peri-procedural death in stenting versus medical therapy for asymptomatic carotid stenosis.
Figure 2.4.
Figure 2.4.
Long-term risk of death in stenting versus medical therapy for asymptomatic carotid stenosis.
Figure 3.1.
Figure 3.1.
Long-term risk of ipsilateral stroke, including peri-procedural stroke in any territory or peri-procedural death in stenting versus endarterectomy for asymptomatic carotid stenosis.
Figure 3.2.
Figure 3.2.
Long-term risk of post-procedural ipsilateral stroke in stenting versus endarterectomy for asymptomatic carotid stenosis.
Figure 3.3.
Figure 3.3.
Long-term risk of stroke in any territory, including peri-procedural death in stenting versus endarterectomy for asymptomatic carotid stenosis.
Figure 3.4.
Figure 3.4.
Long-term risk of major stroke, including peri-procedural death in stenting versus endarterectomy for asymptomatic carotid stenosis.
Figure 3.5.
Figure 3.5.
Long-term risk of death in stenting versus endarterectomy for asymptomatic carotid stenosis.
Figure 3.6.
Figure 3.6.
Risk of peri-procedural stroke in stenting versus endarterectomy for asymptomatic carotid stenosis.
Figure 3.7.
Figure 3.7.
Risk of peri-procedural death in stenting versus endarterectomy for asymptomatic carotid stenosis.
Figure 3.8.
Figure 3.8.
Risk of peri-procedural stroke or death in stenting versus endarterectomy for asymptomatic carotid stenosis.
Figure 3.9.
Figure 3.9.
Risk of peri-procedural major stroke or death in stenting versus endarterectomy for asymptomatic carotid stenosis.
Figure 3.10.
Figure 3.10.
Risk of peri-procedural myocardial infarction in stenting versus endarterectomy for asymptomatic carotid stenosis.
Figure 3.11.
Figure 3.11.
Risk of peri-procedural cranial nerve injury in stenting versus endarterectomy for asymptomatic carotid stenosis.
Figure 4.1.
Figure 4.1.
Long-term risk of ipsilateral stroke, including peri-procedural stroke in any territory or peri-procedural death in endarterectomy versus medical therapy for 30–99% symptomatic carotid stenosis.
Figure 4.1.1.
Figure 4.1.1.
Long-term risk of ipsilateral stroke, including peri-procedural stroke in any territory or peri-procedural death in endarterectomy versus medical therapy for 50–99% symptomatic carotid stenosis. Subgroup: Age.
Figure 4.1.2.
Figure 4.1.2.
Long-term risk of ipsilateral stroke, including peri-procedural stroke in any territory or peri-procedural death in endarterectomy versus medical therapy for 50–99% symptomatic carotid stenosis. Subgroup: Sex.
Figure 4.1.3.
Figure 4.1.3.
Long-term risk of ipsilateral stroke, including peri-procedural stroke in any territory or peri-procedural death in endarterectomy versus medical therapy for 50–99% symptomatic carotid stenosis. Subgroup: Time since last ischaemic event.
Figure 4.1.4.
Figure 4.1.4.
Long-term risk of ipsilateral stroke, including peri-procedural stroke in any territory or peri-procedural death in endarterectomy versus medical therapy for symptomatic carotid stenosis. Subgroup: Severity of stenosis.
Figure 4.2.
Figure 4.2.
Long-term risk of stroke in any territory, including peri-procedural death in endarterectomy versus medical therapy for 30–99% symptomatic carotid stenosis.
Figure 4.2.1.
Figure 4.2.1.
Long-term risk of stroke in any territory, including peri-procedural death in endarterectomy versus medical therapy for symptomatic carotid stenosis. Subgroup: Severity of stenosis.
Figure 4.3.
Figure 4.3.
Long-term risk of major stroke, including peri-procedural death in endarterectomy versus medical therapy for 30–99% symptomatic carotid stenosis.
Figure 4.3.1.
Figure 4.3.1.
Long-term risk of major stroke, including peri-procedural death in endarterectomy versus medical therapy for symptomatic carotid stenosis. Subgroup: Severity of Stenosis.
Figure 4.4.
Figure 4.4.
Long-term risk of death in endarterectomy versus medical therapy for 30–99% symptomatic carotid stenosis.
Figure 6.1.
Figure 6.1.
Long-term risk of ipsilateral stroke, including peri-procedural stroke in any territory or peri-procedural death in stenting versus endarterectomy for symptomatic carotid stenosis.
Figure 6.2.
Figure 6.2.
Long-term risk of post-procedural ipsilateral stroke in stenting versus endarterectomy for symptomatic carotid stenosis.
Figure 6.3.
Figure 6.3.
Long-term risk of stroke in any territory, including peri-procedural death in stenting versus endarterectomy for symptomatic carotid stenosis.
Figure 6.4.
Figure 6.4.
Long-term risk of major stroke, including peri-procedural death in stenting versus endarterectomy for symptomatic carotid stenosis.
Figure 6.5.
Figure 6.5.
Long-term risk of death in stenting versus endarterectomy for symptomatic carotid stenosis.
Figure 6.6.
Figure 6.6.
Long-term risk of severe restenosis in stenting versus endarterectomy for symptomatic or asymptomatic carotid stenosis.
Figure 6.7.
Figure 6.7.
Risk of peri-procedural stroke in stenting versus endarterectomy for symptomatic carotid stenosis.
Figure 6.8.
Figure 6.8.
Risk of peri-procedural death in stenting versus endarterectomy for symptomatic carotid stenosis.
Figure 6.9.
Figure 6.9.
Risk of peri-procedural stroke or death in stenting versus endarterectomy for symptomatic carotid stenosis.
Figure 6.9.1.
Figure 6.9.1.
Risk of peri-procedural stroke or death in stenting versus endarterectomy for symptomatic carotid stenosis. Subgroup: Age.
Figure 6.9.2.
Figure 6.9.2.
Risk of peri-procedural stroke or death in stenting versus endarterectomy for symptomatic carotid stenosis. Subgroup: Sex.
Figure 6.9.3.
Figure 6.9.3.
Risk of peri-procedural stroke or death in stenting versus endarterectomy for symptomatic carotid stenosis. Subgroup: Severity of stenosis.
Figure 6.9.4.
Figure 6.9.4.
Risk of peri-procedural stroke or death in stenting versus endarterectomy for symptomatic carotid stenosis. Subgroup: Time since last ischaemic event.
Figure 6.9.5.
Figure 6.9.5.
Risk of peri-procedural stroke or death in stenting versus endarterectomy for symptomatic carotid stenosis. Subgroup: Type of last ischaemic event.
Figure 6.10.
Figure 6.10.
Risk of peri-procedural major stroke or death in stenting versus endarterectomy for symptomatic carotid stenosis.
Figure 6.11.
Figure 6.11.
Risk of peri-procedural myocardial infarction in stenting versus endarterectomy for symptomatic carotid stenosis.
Figure 6.12.
Figure 6.12.
Risk of peri-procedural cranial nerve injury in stenting versus endarterectomy for symptomatic carotid stenosis.

Source: PubMed

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