mardi 10 mai 2016

Asymptomatic carotid stenosis (ACS) : medical treatment is the rule, surgery or CAS only in RCT

These patients need Best Medical Treatment and often they don't get it.
Statin: atorvastatin
For diabetics
"In conclusion, ACE inhibitors should be given to all type 1 diabetic patients with microalbuminuria or nephropathy, and to type 2 patients with hypertension, microalbuminuria, or existing cardiovascular disease. All diabetic patients with hypertension and left ventricular hypertrophy should have an ARB such as losartan as first-line therapy."

Instead of operating on patients without symptoms verify that the BMT is prescribed and is working:
Non HDL cholesterol
LDL cholesterol
Ambulatory measure of Arterial Pressure
No arrhythmia
Efficient antiplatelet treatment.

More don't be fooled by the medical illusion:
Look at your complications first.

Then don't be fooled by mathematics used in statistics

Are there evidence based indications of revascularization in ACS above 80% with special features?
All those indications are a matter of personalised medicine and very few scientific evidence back such indications. No RCT, only case reports and small series could be taken in account in these cases:
1/ Contralateral thrombosis
2/ Documented non focal symptoms like hemodynamic symptoms correlated with Willis anomalies and brain flow imaging
3/ Progressing stenosis despite BMT above 80% in verified NASCET measurement (angio or angioCT)
4/ Silent emboli without any other cause (heart, aorta, blood)
5/ Focal symptoms of more than 6 months

Keep in mind that those patients are not many perhaps 5%.

To bring a benefit to those patients the vascular team should keep the peri-operative mortality to 0%, the perioperative morbidity inferior to 3% and the perioperative permeability above 98%.

In conclusion ACS patients should be randomized in RCT instead of being operated on without clear benefit.

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