D'Oria, Mario

Lepidi, Sandro

English

Archivio istituzionale della ricerca - Università di Trieste

Nothing New Under the Sun of the European Society for Vascular SurgeryCarotid GuidelinesSandro Lepidi *, Mario D’OriaDivision of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste, ASUGI, Trieste, ItalyIn the last decade, a great debate has been taking place on with those with no symptoms. There were no significantthe real benefit of invasive treatment for asymptomaticcarotid stenosis (ACS) owing to the significant improve-ments in medical therapy and cardiovascular risk reductionstrategies. The unresolved question is whether carotidendarterectomy (CEA) or carotid artery stenting plus bestmedical therapy (BMT) are still superior to BMT alone in theprevention of stroke in patients with ACS. Much researchfocus has therefore been undertaken to identify specificsubgroups of patients with ACS that may present anincreased risk of stroke while on BMT alone. The interestingwork by Morris and colleagues1 falls within this context andmay provide further evidence.Their prospective cohort study investigated the risk ofstroke in patients without classical symptoms of transientischaemic attack (TIA) or stroke. A total of 504 patients witha 50 e 99% carotid artery stenosis were enrolled and fol-lowed for a median of 5.1 years. The authors focused onpatients presenting with non-focal neurological symptoms(n ¼ 47), focal symptoms > 6 months earlier (n ¼ 82), andthose with prior contralateral CEA (n ¼ 71). The remainingcontrol group patients (n ¼ 304) were defined by the au-thors as those with no symptoms. The primary outcome wasipsilateral ischaemic stroke, and secondary outcomes wereany ischaemic stroke as well as cardiovascular death.ACS refers to a stenosis detected in patients without anyclinical history of ipsilateral ischaemic stroke, TIA, or otherneurological symptoms, which might be referable to thecarotid arteries within the preceding six months.2 The termnon-hemispheric or non-focal symptoms is applied to pa-tients with isolated syncope (blackout, drop attack), pre-syncope (faintness), isolated dizziness, isolated doublevision (diplopia), tinnitus, and isolated vertigo. There is noevidence that patients with non-hemispheric symptomsbenefit from carotid (or vertebral) interventions.3In the study by Morris et al, there were no statisticallysignificant differences in the annual rate of ipsilateral strokeamong people with non-focal symptoms, prior contralateralCEA, or ipsilateral symptoms > 6 months earlier compared* Corresponding author. Professor and Chief of Vascular and Endovascular SurgerFiume 447, 34149 Trieste, Italy.E-mail address: slepidi@units.it; (Sandro Lepidi).1differences in secondary outcomes across groups. The au-thors concluded that non-focal symptoms are not a warningsign of high risk of stroke.Despite the potential relevance of this study, which certainlyadds to our knowledge, many limitations exist, and theseshould be carefully evaluated in order to appreciate the studyfindings with an appropriate perspective. Moreover, the 2017European Society for Vascular Surgery (ESVS) guidelines4 werethe first to propose clinical and imaging criteria (maintainedunchanged in the 2023 ESVS guidelines3) for identifying ahigher risk of stroke in the BMT cohort in whom CEA or carotidartery stenting might be targeted. Criteria include silentinfarction on CT/MRI,  20% stenosis progression, large pla-que area or large juxtaluminal black area on computerisedultrasound plaque analysis, plaque echolucency, intraplaquehaemorrhage on MRI, impaired cerebral vascular reserve, andat least one spontaneous micro-embolic signal during  1hour of transcranial Doppler monitoring. Unfortunately, noneof these cohorts of ACS patients were analysed in the study byMorris and colleagues, thereby limiting our ability to lookdeeper into probably more interesting subsets of ACS patients.REFERENCES1 Morris DR, Singh TP, Zaman T, Velu R, Quigley F, Jenkins J, et al.Rates of stroke in patients with different presentations of carotidartery stenosis. Eur J Vasc Endovasc Surg 2023;66:484e91.2 Halliday A, Mansfield A, Marro J, Peto C, Peto R, Potter J, et al.;MRC Asymptomatic Carotid Surgery Trial (ACST) CollaborativeGroup. Prevention of disabling and fatal strokes by successful carotidendarterectomy in patients without recent neurological symptoms:randomised controlled trial. Lancet 2004;363:1491e502.3 Naylor R, Rantner B, Ancetti S, de Borst GJ, De Carlo M, Halliday A,et al. Editor’s Choice e European Society for Vascular Surgery(ESVS) 2023 clinical practice guidelines on the management ofatherosclerotic carotid and vertebral artery disease. Eur J VascEndovasc Surg 2023;65:7e111.4 Naylor AR, Ricco JB, de Borst GJ, Debus S, de Haro J, Halliday A,et al. Editor’s Choice e Management of atherosclerotic carotid andvertebral artery disease: 2017 clinical practice guidelines of theEuropean Society for Vascular Surgery (ESVS). Eur J Vasc EndovascSurg 2018;55:3e81.y, Cardiovascular Department, University Hospital of Trieste, ASUGI, Strada di

Nothing New Under the Sun of the European Society for Vascular Surgery Carotid Guidelines

Sandro Lepidi

Mario D’Oria

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https://arts.units.it/bitstream/11368/3066904/3/Nothing%2bNew-Post_print.pdf

Nothing New Under the Sun of the European Society for Vascular Surgery Carotid Guidelines

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