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Neurointervention > Volume 18(1); 2023 > Article |
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Types of carotid stenosis | CEA* ↔ BMT | CAS* ↔ BMT | CAS ↔ CEA |
---|---|---|---|
Symptomatic | NASCET (1991) | EVA-3S (2006) | |
ECST (1998) | SPACE (2006) | ||
ICSS (2010) | |||
CAVATAS (2010) | |||
Mixed | ECST-2 (ongoing)† | ECST-2 (ongoing)† | SAPPHIRE (2004, 2008) |
CREST (2010) | |||
Asymptomatic | VACS (1993) | SPACE-2 (2022)‡ | ACT (2016) |
ACAS (1995) | CREST-2 (ongoing)§ | ACST-2 (2021) | |
ACST (2004) | SPACE-2 (2022)‡ | ||
SPACE-2 (2022)‡ | |||
CREST-2 (ongoing)§ | |||
ACTRIS (ongoing) |
CEA, carotid endarterectomy; BMT, best medical treatment; CAS, carotid artery stenting; NASCET, North American Symptomatic Carotid Endarterectomy Trial; ECST, European Carotid Surgery Trial; EVA-3S, Endarterectomy vs. Stenting in patients with Symptomatic Severe carotid Stenosis; SPACE, Stent-Protected Angioplasty vs. Carotid Endarterectomy; ICSS, International Carotid Stenting Study; CAVATAS, Carotid and Vertebral Artery Transluminal Angioplasty Study; SAPPHIRE, Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy; CREST, Carotid Revascularization Endarterectomy vs. Stenting Trial; VACS, Veterans Affairs Carotid Study; ACAS, Asymptomatic Carotid Atherosclerosis Study; ACST, Asymptomatic Carotid Surgery Trial; ACT, Asymptomatic Carotid Trial; ACTRIS, Asymptomatic Severe Atherosclerotic Carotid Artery Stenosis at Higher than Average Risk of Ipsilateral Stroke.
SAPPHIRE [9] | CREST [10] | ACT [11] | ACST-2 [12] | SPACE-2 [13] | ||||
---|---|---|---|---|---|---|---|---|
Characteristic | ||||||||
Year of publication | 2004*; 2008† | 2010 | 2016 | 2021 | 2022 | |||
Number of patients included | 334*; 260† | 2,502 | 1,453 | 3,625 | 513 | |||
Asymptomatic cases | 70.1% | 47.2% | 100% | 100% | 100% | |||
Number of patients with CAS | 167*; 143† | 1,262 | 1,089 | 1,811 | 197 | |||
Stenosis cutoff for trial inclusion‡ | ≥80%§ | ≥60% or ≥70%| | ≥70%¶ | ≥60%§ | ≥50%§,** | |||
Periprocedural (or procedural) outcome†† | ||||||||
Stroke, myocardial infarction, or death | 4.8% ↔ 9.8% (P=0.09) | 5.2% ↔ 4.5% (P=0.38) | 3.3% ↔ 2.6% (P=0.60) | 3.9% ↔ 3.2% (P=0.26) | 2.5% ↔ 2.5% (P=0.96)§§ | |||
Stroke or death | 4.4% ↔ 2.3% (P<0.01)‡‡ | 2.9% ↔ 1.7% (P=0.33) | ||||||
Disabling stroke or death | 0.9% ↔ 1.0% (P=0.77) | 0.5% ↔ 0.5% (P=0.98) | ||||||
Stroke | 4.1% ↔ 2.3% (P=0.01) | 2.8% ↔ 1.4% (P=0.23) | 3.6% ↔ 2.4% (P=0.06) | |||||
Death | 0.7% ↔ 0.3% (P=0.18) | 0.1% ↔ 0.3% (P=0.43) | ||||||
Long-term outcome | ||||||||
Follow-up period | 1 y* and 3 y† | 4 y | 1 y* and 5 y|| | 5 y | 5 y | |||
All events | ||||||||
Composite outcomes | ||||||||
Periprocedural stroke, myocardial infarction, or death or postprocedural ipsilateral stroke | 12.2% ↔ 20.1%; P<0.01 for noninferiority of CAS*,¶¶ 24.6% ↔ 26.9% (P=0.71)† | 7.2% ↔ 6.8% (P=0.51)¶¶ | 3.8% ↔ 3.4%; P=0.01 for noninferiority of CAS*,¶¶ | |||||
Periprocedural stroke or death or postprocedural ipsilateral stroke | 6.4% ↔ 4.7% (P=0.03) | 4.4% ↔ 2.5% (P=0.37)¶¶,*** | ||||||
Periprocedural stroke or postprocedural ipsilateral stroke | 6.2% ↔ 4.7% (P=0.04) | |||||||
Individual outcomes | ||||||||
Any stroke | 10.2% ↔ 7.9% (P=0.03) | 6.9% ↔ 5.3% (P=0.44)|| | 9.2% ↔ 5.3% (P=0.19) | |||||
Ipsilateral stroke | 4.4% ↔ 2.0% (P=0.23) | |||||||
Death | 11.3% ↔ 12.6% (P=0.45) | 12.9% ↔ 10.6% (P=0.21)|| | 9.3% ↔ 7.6% (P=0.62) | |||||
Postprocedural (or non-procedural) events | ||||||||
Stroke | 5.2% ↔ 4.5% (P=0.33)¶¶ | |||||||
Ipsilateral stroke | 2.0% ↔ 2.5% (P=0.85) | 2.2% ↔ 2.7% (P=0.51)|| | ||||||
Fatal or disabling stroke | 2.4% ↔ 2.5% (P=0.91) |
Event frequencies are represented by “% in the CAS group ↔ % in the CEA group (P-value)”.
CAS, Carotid artery stenting; CEA, carotid endarterectomy; SAPPHIRE, Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy; CREST, Carotid Revascularization Endarterectomy vs. Stenting Trial; ACT, Asymptomatic Carotid Trial; ACST, Asymptomatic Carotid Surgery Trial; SPACE, Stent-Protected Angioplasty vs. Carotid Endarterectomy.
** ≥50% according to North American Symptomatic Carotid Endarterectomy Trial (NASCET) criteria and ≥70% according to European Carotid Surgery Trial (ECST) criteria;
AHA/ASA (2014) [26] | ESVS (2017) [1] | SVS (2021) [28] | ESO (2021) [29] | ||||
---|---|---|---|---|---|---|---|
To assess the risk and benefit of revascularization treatment | |||||||
(1) Stenosis degree (see Table 4 and 5) | |||||||
For CEA | >70% | ≥60% | ≥70%* | ≥60% | |||
For CAS | ≥60% or ≥70%† | ≥60% | ≥70% | ≥60%‡ | |||
(2) Life expectancy | NS | >5 y | ≥3–5 y | ≥5 y | |||
(3) Stroke risk by medical treatment (see Table 6) | NS | Consider higher risk for stroke on best medical therapy | NS | Consider the increased risk of stroke on medical treatment | |||
To determine the type of revascularization treatment | |||||||
(4) Availability of vascular surgeon | |||||||
(5) High risk for CEA or CAS (see Table 7) | |||||||
Treatment of preference | CEA | CEA | CEA | CEA | |||
Position of CAS | |||||||
To CEA | NS | May be considered for patients high-risk for CEA | Should be considered for patients high-risk for CEA | May be suggested for patients less suitable for surgery| | |||
Insufficient data to recommend as primary therapy | |||||||
To medical treatment | Might be considered for highly-selected patients§, but its effectiveness is not well established compared with medical therapy alone | NS | NS | Recommend against as a routine alternative to best medical therapy alone | |||
At high risk for CEA or CAS, the effectiveness of revascularization vs. medical therapy alone is not well established | |||||||
Peri-revascularization treatment risk | |||||||
Perioperative risk¶ | <3% | <3% | ≤3% | <2% | |||
Periprocedural risk** | NS | <3% | <3% | <2% |
Carotid endarterectomy |
Carotid artery stenting |
||||||
---|---|---|---|---|---|---|---|
≥60% | ≥70% | ≥80% | ≥60% | ≥70% | ≥80% | ||
Guideline from | |||||||
Stroke Council of AHA (1998)*, [18] | ● | ||||||
National Stroke Association (1999)*, [19] | ● | ||||||
AHA/ASA (2006)*, [20] | ● | ||||||
SVS (2008)*, [21] | ● | ||||||
ESVS (2009) [22] | ● | ○ | |||||
AHA/ASA (2011)†, [23] | ● | ● | ● | ● | ● | ||
ESC (2011) [24] | ● | ○ | |||||
SVS (2011)‡, [25] | ● | ||||||
AHA/ASA (2014)†, [26] | ●§ | ● | ● | ||||
ESVS (2017) [1] | ● | ● | |||||
German/Austrian society (2020) [27] | ● | ● | |||||
SVS (2021) [28] | ● | ● | |||||
ESO (2021) [29] | ● | ○ |
●=The degree of stenosis is specified in the guideline; ○=The degree of stenosis is not specified in the guideline, but CAS is simply allowed as an alternative to CEA.
AHA, American Heart Association; ASA, American Stroke Association; SVS, Society of Vascular Surgery; ESVS, European Society for Vascular Surgery; ESC, European Society of Cardiology; ESO, European Stroke Organization.
Stenosis degree cutoff for carotid artery stenting |
|||||
---|---|---|---|---|---|
≥50% | ≥60% | ≥70% | ≥80% | ||
Randomized trials | |||||
SAPPHIRE [9] | DUS | ||||
CREST [10] | Angiography* | DUS | |||
ACT [11] | DUS; Angiography* | ||||
ACST-2 [12] | DUS | ||||
SPACE-2 [13] | DUS | ||||
Guidelines from | |||||
ESVS (2009) [22] | -† | ||||
AHA/ASA (2011) [23] | Angiography* | DUS | CTA or MRA‡ | ||
ESC (2011) [24] | DUS; CTA; and/or MRA | ||||
AHA/ASA (2014) [26] | Angiography* | DUS | |||
ESVS (2017) [1] | DUS; CTA; and/or MRA | ||||
German/Austrian society (2020) [27] | DUS§ | ||||
SVS (2021) [28] | DUS| | ||||
ESO (2021) [29] | -† |
SAPPHIRE, Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy; DUS, duplex ultrasonography; CREST, Carotid Revascularization Endarterectomy vs. Stenting Trial; ACT, Asymptomatic Carotid Trial; ACST, Asymptomatic Carotid Surgery Trial; SPACE, Stent-Protected Angioplasty vs. Carotid Endarterectomy; ESVS, European Society for Vascular Surgery; AHA, American Heart Association; ASA, American Stroke Association; CTA, computed tomography angiography; MRA, magnetic resonance angiography; ESC, European Society of Cardiology; SVS, Society of Vascular Surgery; ESO, European Stroke Organization.
Stenosis | Feature | Study type | Category | Stroke risk (%/y) | OR or HR |
---|---|---|---|---|---|
≥50% | Stenosis degree [30] | Meta-analysis | 50%–69% | 1.6 | |
70%–99% | 2.4 | ||||
Stenosis progression [32] | Observational | Regression | 0.0* | ||
No change | 1.1 | ||||
Progression (at least 10%) | 2.0 | 1.92 (1.14–3.25) | |||
Intraplaque hemorrhage on MRI [36] | Meta-analysis | 3.66 (2.70–4.95) | |||
Plaque lucency on duplex ultrasonography [35] | Meta-analysis | Predominantly echolucent | 4.2† | 2.61 (1.47–4.63) | |
Predominantly echogenic | 1.6 | ||||
Juxta-luminal hypoechoic area‡, [37] | Observational | <4 mm2 | 0.4§ | ||
4–8 mm2 | 1.4 | ||||
8–10 mm2 | 3.2 | ||||
>10 mm2 | 5.0 | ||||
Spontaneous embolization on TCD [41] | Meta-analysis | 6.63 (2.85–15.4) | |||
Contralateral TIA or stroke [39] | Observational | Yes | 3.4† | 3.00 (1.90–4.73) | |
No | 1.2 | ||||
≥60% | Silent infarction on CT [38] | Observational | Yes | 3.6† | 3.00 (1.46–6.29) |
No | 1.0 | ||||
≥70% | Stenosis progression [31] | RCT | No change | Reference | |
Progression, 1 stenosis grade| | 1.65 (1.10–2.45) | ||||
Progression, 2 stenosis grades | 4.73 (2.23–9.64) | ||||
Impaired cerebrovascular reserve [40] | Meta-analysis | 6.14 (1.27–29.5) | |||
Plaque area‡, [33] | Observational | <40 mm2 | 1.0 | Reference | |
40–80 mm2 | 1.4 | 2.08 (1.05–4.12) | |||
>80 mm2 | 4.6 | 5.81 (2.67–12.7) | |||
Spontaneous embolization with echolucent plaque [42] | Observational | Yes | 8.9† | 10.6 (2.98–37.8) | |
No | 0.8 |
Modified from the European Society for Vascular Surgeon (2017) [1] and German/Austrian (2020) guidelines, [27] based on individual reports.
OR, odds ratio; HR, hazard ratio; MRI, magnetic resonance imaging; TCD, transcranial doppler; TIA, transient cerebral ischemic attack; CT, computed tomography; RCT, randomized controlled trial.
Non-vascular | Vascular | Medical | |
---|---|---|---|
High risk for CEA | Lesion above C2 | Contralateral carotid occlusion | Age ≥75* or >80† y old |
Previous neck surgery; tracheal stoma; neck irradiation; recurrent stenosis (reoperation) after prior CEA | Severe tandem lesions‡ | Clinically-significant cardiac diseases (congestive heart failure with NYHA functional class III/IV; left ventricular ejection fraction ≤30%–35%; 2 diseased coronaries with ≥70% stenosis; unstable angina; myocardial infarction within 6 wk or 30 d; abnormal stress test; need for or planned open heart surgery within 30 d) | |
Hostile neck owing to obesity, spinal immobility, or kyphosis | Severe pulmonary disease | ||
Contralateral vocal cord injury or laryngeal nerve palsy | Chronic renal insufficiency (or severe renal disease) | ||
Uncontrolled diabetes | |||
High risk for CAS | Tortuous ICA or CCA; heavy atherosclerotic burden of arch; type III or tortuous aortic arch; severe aortic stenosis | Age >70§, >75*,|, or >80* y old | |
Chronic renal insufficiency (or severe renal disease) | |||
Heavily-calcified carotid stenosis; complex or circumferential bifurcation stenosis >15 mm length | Decreased cerebral reserve | ||
Lesion-related thrombus | Dementia |
Merged and resummarized from the European Society for Vascular Surgery (ESVS, 2017) guideline, the Society of Vascular Surgery (SVS, 2021) guideline, and related articles. [1,7,28]
CEA, carotid endarterectomy; CAS, carotid artery stenting; NYHA, New York Heart Association; ICA, internal carotid artery; CCA, common carotid artery.
| White et al. J Am Coll Cardiol 2022;80:155-170. [7]