The most important recommendationsfrom the 2017 ESVS/ESC guideline on

the management of carotid arterydisease

GJ de Borst

Department of Vascular Surgery

RECOMMENDATION GRADING CRITERIA

What is new in the 2017 Guidelines?

1. Evidence update regarding stroke prevention in patients with Asx & Sx carotid disease

2. Evidence for treatment of atherosclerotic vertebral artery disease

3. Selected unresolved issues

1. Evidence update regarding stroke prevention in patients with Asx & Sx carotid disease

What is new in the 2017 Guidelines? II

Evidence for patching, shunting, eversion CEA, protamine reversal, treatment of coils/kinks, etc

Evidence supporting rapid interventions in recently Sx patients and timing of carotid interventions after

intracranial thrombolysis

CEA/CAS complications: stroke, hypotension,

hypertension, CNI, patch infection, restenosis

Identification of ‘high risk for stroke’ asymptomaticpatients on BMT

Arch Neurol 2003;60:774

Do the facts & figures warrant a 10-fold increase in theperformance of carotid surgery in asymptomatic patients?Barnett HJM, Eliasziw M, Meldrum HE, Taylor DW

Asymptomatic Carotid Stenosis: Mainly a Medical ConditionJ David Spence

OPINION

Clinical history of contralateral TIA/stroke RCT, multicentre

CT/MRI ipsilateral silent infarction RCT, multicentre

Ultrasound imaging

stenosis progression (>20%)

spontaneous embolisation on TCDimpaired cerebral vascular reservelarge volume plaques (>80mm2)

echolucent plaqueslarge juxta-luminal black area (>8mm2)

RCT, multicentremulticentre

meta-analysismulticentre

Meta-analysismulticentre

MRA intra-plaque haemorrhagelipid rich necrotic core

meta-analysismeta-analysis

Clinical/imaging features that may be associated with an increased risk of stroke on BMT

Lexington CREST-1 ACT-1 SPACE-2 Mannheim

CEAn=42

CASn=43

CEAn=587

CASn=364

CEAn=364

CASn=1089

CEAn=203

CASn=197

CEAn=68

CASn=68

0.0% 0.0% 1.4% 2.5% 1.7% 2.9% 2.0% 2.5% 1.5% 2.9%

Meta-analysis: 30-day stroke/death 2017 ESVS Carotid &Vertebral Guidelines

Eckstein EJVES 2017

“Some recommendations sound conservative (eg therather restrictive recommendations for CEA and CAS in asymptomatic

carotid stenosis). Some patients and physicians will probably not accept that surgical or endovascular therapy will be denied as long

as no symptoms occur”.

Recommendation 40 Class Level

When revascularisation is considered in symptomatic patients with 50-99% stenoses, it

is recommended that this be performed as soon as possible, preferably within 14 days of symptom onset

I A

Timing of CEA/CAS in symptomatic patients

Recommendation 41 Class Level

Patients who are to undergo revascularisation within the first 14 days after symptom onset

should undergo carotid endarterectomy, rather than carotid stenting

I A

EVA-3S + SPACE + ICSS

30-day death/stroke

CAS CEA p=

0-7 days 9.4% 2.8% p=0.03

8-14 days 8.1% 3.4% p=0.04

J Vasc Surg 2013

Definition of INDEX event

Study Inclusion period Definition of timing

Brooks NR Event to revascularisation

Witt NR NR

CAVATAS 1992-1997 Randomisation to revascularisation

BACASS 1998-2002 Symptomatic in the past 3 months

Steinbauer 1999-2002 NR

SAPPHIRE 2000-2002 NR

EVA-3S 2000-2008 Event to revascularisationRandomisation to revascularisation

CREST 2000-2008 Event to revascularisationEvent to randomisationRandomisation to revascularisation

SPACE 2001-2006 Randomisation to revascularisation

ICSS 2001-2008 Event to revascularisationRandomisation to revascularisation

Felli 2008-2011 Symptomatic in the past 3 months

Kuliha 2011-2013 Event to revascularisation

NR = not reported

Delay in recent RCTs on CAS vs CEA

CAVATAS EVA-3S SPACE ICSS CREST

Inclusion Sx / 6 mths Sx > 60/4m Sx >70% Sx >50% /12m

Sx/6 mths

Time from qualifying event to treatment

NA < 14d CAS

20%

< 14d CEA

16%

NR CAS 35 (15-82)

< 14d: 25%

CEA 40(18-87< 14d:

18%

CAS 36.3 +-39.6

CEA 40.9 +-43

2. Evidence for treatment of atherosclerotic vertebral artery disease

Vertebral artery disease

Recommendation 103 Class LevelAsymptomatic vertebral artery atherosclerotic lesions should not be treated by open or endovascular interventions

III C

Recommendation 113 Class Level

Patients with recurrent vertebrobasilar territory symptoms (despite BMT) and who have a 50-99% extracranial VA stenosis may be considered for revascularisation

IIb B

3. Selected unresolved issues

Selected unresolved carotid issues

Acute stroke patients with tandem lesions undergoing intracranial thrombectomy: staged or deferred CEA/CAS?

Relevance of new DWI-MRI lesions after CEA & CAS. Do these contribute towards cognitive decline?

Should accepted risk thresholds for CEA/CAS be reduced from 6% (symptomatic) and 3% (asymptomatic)?

Selected unresolved carotid issues

Does the location of VA stenoses in symptomatic patients influence decisions regarding intervention or BMT?

Paola de Rango