mardi 18 avril 2017

Asymptomatic atheromatous carotid lesion: change of paradigm.


●Asymptomatic carotid atherosclerotic disease refers to the presence of atherosclerotic narrowing of the extracranial internal carotid artery in individuals without a history of recent ipsilateral carotid territory ischemic stroke or transient ischemic attack. The most feared outcome of carotid atherosclerosis is ischemic stroke. The estimated risk of ipsilateral stroke in patients with asymptomatic carotid atherosclerosis (stenosis ≥50 percent) is approximately 0.5 to 1.0 percent annually. Asymptomatic carotid atherosclerosis is also a marker of increased risk for myocardial infarction and vascular death. (See 'Scope of the problem' above.)

●Patients with asymptomatic carotid atherosclerosis should receive intensive medical therapy using all available risk reduction strategies including statin therapy, antiplatelet therapy, blood pressure control, and lifestyle modification consisting of smoking cessation, limited alcohol consumption, weight control, regular aerobic physical activity, and a Mediterranean diet. (See 'Our approach' above and 'Medical management' above.)

●For medically stable patients who have a life expectancy of at least five years and a high grade (≥80 percent) asymptomatic carotid stenosis at baseline or have progression to ≥80 percent stenosis despite intensive medical therapy while under observation, we suggest carotid endarterectomy (CEA), provided the combined perioperative risk of stroke and death is less than 3 percent for the surgeon and center (Grade 2B). (See 'Our approach' above and 'Carotid endarterectomy' above and 'Identifying high stroke risk' above.)

●CEA in asymptomatic patients should be considered a long-term investment, as the benefit of CEA for asymptomatic disease emerges only after a number of years. (See 'Delay to benefit' above.)

●Accumulating evidence suggests that both carotid artery angioplasty and stenting (CAS) and CEA provide similar long-term outcomes for patients with asymptomatic and symptomatic carotid occlusive disease. However, the periprocedural risk of stroke and death is higher with CAS. We suggest not treating asymptomatic carotid artery stenosis with CAS unless it is performed in the context of a clinical trial in centers with demonstrated low (<3 a="" and="" combined="" death="" for="" href="" percent="" periprocedural="" risk="" stroke="">Grade 2B). (See 'Carotid stenting' above.)