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How to identify which patients with asymptomatic carotid stenosis could benefit from endarterectomy or stenting

Offering routine carotid endarterectomy (CEA) or carotid artery stenting (CAS) to patients with asymptomatic carotid artery stenosis (ACS) is no longer considered as the optimal management of these patients. Equally suboptimal, however, is the policy of offering only best medical treatment (BMT) to...

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Autores principales: Paraskevas, Kosmas I, Veith, Frank J, Spence, J David
Formato: Online Artículo Texto
Lenguaje:English
Publicado: BMJ Publishing Group 2018
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6047337/
https://www.ncbi.nlm.nih.gov/pubmed/30022795
http://dx.doi.org/10.1136/svn-2017-000129
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author Paraskevas, Kosmas I
Veith, Frank J
Spence, J David
author_facet Paraskevas, Kosmas I
Veith, Frank J
Spence, J David
author_sort Paraskevas, Kosmas I
collection PubMed
description Offering routine carotid endarterectomy (CEA) or carotid artery stenting (CAS) to patients with asymptomatic carotid artery stenosis (ACS) is no longer considered as the optimal management of these patients. Equally suboptimal, however, is the policy of offering only best medical treatment (BMT) to all patients with ACS and not considering any of them for prophylactic CEA. In the last few years, there have been many studies aiming to identify reliable predictors of future cerebrovascular events that would allow the identification of patients with high-risk ACS and offer a prophylactic carotid intervention only to these patients to prevent them from becoming symptomatic. All patients with ACS should receive BMT. The present article will summarise the evidence suggesting ways to identify these high-risk asymptomatic individuals, namely: (1) microemboli detection on transcranial Doppler, (2) plaque echolucency on Duplex ultrasound, (3) progression in the severity of ACS, (4) silent embolic infarcts on brain CT/MRI, (5) reduced cerebrovascular reserve, (6) increased size of juxtaluminal hypoechoic area, (7) identification of intraplaque haemorrhage using MRI and (8) carotid ulceration. The evidence suggests that approximately 10%–15% of patents with asymptomatic stenosis might benefit from intervention; this will become more clear after publication of ongoing studies comparing stenting or endarterectomy with best medical therapy. In the meantime, no patient should be offered intervention unless there is evidence of high risk of ipsilateral stroke, from modalities such as those discussed here.
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spelling pubmed-60473372018-07-18 How to identify which patients with asymptomatic carotid stenosis could benefit from endarterectomy or stenting Paraskevas, Kosmas I Veith, Frank J Spence, J David Stroke Vasc Neurol Review Offering routine carotid endarterectomy (CEA) or carotid artery stenting (CAS) to patients with asymptomatic carotid artery stenosis (ACS) is no longer considered as the optimal management of these patients. Equally suboptimal, however, is the policy of offering only best medical treatment (BMT) to all patients with ACS and not considering any of them for prophylactic CEA. In the last few years, there have been many studies aiming to identify reliable predictors of future cerebrovascular events that would allow the identification of patients with high-risk ACS and offer a prophylactic carotid intervention only to these patients to prevent them from becoming symptomatic. All patients with ACS should receive BMT. The present article will summarise the evidence suggesting ways to identify these high-risk asymptomatic individuals, namely: (1) microemboli detection on transcranial Doppler, (2) plaque echolucency on Duplex ultrasound, (3) progression in the severity of ACS, (4) silent embolic infarcts on brain CT/MRI, (5) reduced cerebrovascular reserve, (6) increased size of juxtaluminal hypoechoic area, (7) identification of intraplaque haemorrhage using MRI and (8) carotid ulceration. The evidence suggests that approximately 10%–15% of patents with asymptomatic stenosis might benefit from intervention; this will become more clear after publication of ongoing studies comparing stenting or endarterectomy with best medical therapy. In the meantime, no patient should be offered intervention unless there is evidence of high risk of ipsilateral stroke, from modalities such as those discussed here. BMJ Publishing Group 2018-02-24 /pmc/articles/PMC6047337/ /pubmed/30022795 http://dx.doi.org/10.1136/svn-2017-000129 Text en © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted. This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
spellingShingle Review
Paraskevas, Kosmas I
Veith, Frank J
Spence, J David
How to identify which patients with asymptomatic carotid stenosis could benefit from endarterectomy or stenting
title How to identify which patients with asymptomatic carotid stenosis could benefit from endarterectomy or stenting
title_full How to identify which patients with asymptomatic carotid stenosis could benefit from endarterectomy or stenting
title_fullStr How to identify which patients with asymptomatic carotid stenosis could benefit from endarterectomy or stenting
title_full_unstemmed How to identify which patients with asymptomatic carotid stenosis could benefit from endarterectomy or stenting
title_short How to identify which patients with asymptomatic carotid stenosis could benefit from endarterectomy or stenting
title_sort how to identify which patients with asymptomatic carotid stenosis could benefit from endarterectomy or stenting
topic Review
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6047337/
https://www.ncbi.nlm.nih.gov/pubmed/30022795
http://dx.doi.org/10.1136/svn-2017-000129
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