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Surgical Treatment of Significant Asymptomatic Carotid Stenosis: for the Motion
Letter to the Editor Surgical Treatment of Significant Asymptomatic Carotid Stenosis: for the Motion
LETTER: quality of intensive medical therapy (IMT) for asymptomatic T hecarotid stenosis (ACS) has improved greatly over the years, and some experts currently consider IMT for ACS as effective as surgical revascularization in reducing the risk of stroke.1,2 The “IMT-alone” concept, however, has some bias due to the lack of standardization, even in presence of solid benchmarks. For example, there is still no accord on the optimal drugs for blood pressure control and lipid lowering. Even antiplatelet therapy is not yet standardized. Moreover, Park et al.3 reported that during a mean follow-up of 49 months, the incidence of carotid stenosis progression in 129 patients with asymptomatic moderate ACS was high, despite the use of aspirin and statin. Finally, many patients in the real world don’t adhere to therapy because of a poor compliance and/or side effects.4 An ACS in a healthy patient may probably cause a lower risk of stroke compared with an ACS in a patient with a history of smoke, diabetes, hypertension, and dyslipidemia. Or maybe not? This should be still demonstrated. Actually, a subgroup of ACS with higher risk of stroke could be identified, based on specific features. For example, asymptomatic embolism assessed by transcranial Doppler5 and features of carotid plaque morphology (such as ulcerations and intraplaque hemorrhage) could contribute to increase the risk of stroke.6 This subgroup of patients may benefit from a surgical revascularization rather than IMT alone. Furthermore, some “real-world” experiences in the literature coming from high-volume centers with a long-term follow-up suggest that both carotid endarterectomy (CEA) and carotid artery stenting could be performed with a periprocedural neurologic risk lower than 1%.7 Also, in our experience, we observed a greater risk of death and stroke at 1 year in both symptomatic and asymptomatic patients who were treated using IMT alone.8 Eventually, a recent trial comparing CEA associated with IMT against IMT alone was stopped and judged to be unethical
980
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because there was a demonstrated overwhelming superiority of CEA þ IMT in protecting patients from stroke and death, during a median follow-up of 3.3 years.9 Stronger evidence is needed to bring light in the shadows. While we wait, the application of respective national guidelines is mandatory, and the best therapy should be customized to each patient. Daniela Mazzaccaro1, Giovanni Romagnoni1, Alberto Maria Settembrini1, Giovanni Nano1,2 From the 1First Unit of Vascular Surgery, IRCCS Policlinico San Donato, San Donato Milanese, Milan; and 2Department of Biomedical Sciences for Health, University of Milan, Milan, Italy To whom correspondence should be addressed: Daniela Mazzaccaro, M.D. [E-mail: [email protected]; [email protected]] http://dx.doi.org/10.1016/j.wneu.2017.07.116.
REFERENCES 1. Abbott AL. Medical (nonsurgical) intervention alone is now best for prevention of stroke associated with asymptomatic severe carotid stenosis: results of a systematic review and analysis. Stroke. 2009;40:e573-e583. 2. Spence JD. Asymptomatic carotid stenosis. Circulation. 2013;127:739-742. 3. Park YJ, Kim DI, Kim GM, Kim DK, Kim YW. Natural history of asymptomatic moderate carotid artery stenosis in the era of medical therapy. World Neurosurg. 2016;91:247-253. 4. Naderi SH, Bestwick JP, Wald DS. Adherence to drugs that prevent cardiovascular disease: meta-analysis on 376,162 patients. Am J Med. 2012;125:882-887.e1. 5. Spence JD, Coates V, Li H, Tamayo A, Muñoz C, Hackam DG, et al. Effects of intensive medical therapy on microemboli and cardiovascular risk in asymptomatic carotid stenosis. Arch Neurol. 2010;167:180-186. 6. Huibers A, de Borst GJ, Bulbulia R, Pan H, Halliday A, ACST-1 collaborative group. Plaque echolucency and the risk of ischaemic stroke in patients with asymptomatic carotid stenosis within the First Asymptomatic Carotid Surgery Trial (ACST-1). Eur J Vasc Endovasc Surg. 2016;51:616-621. 7. Nano G, Stegher S, Occhiuto MT, Muzzarelli L, Malacrida G, Mazzaccaro DP. A 16-year experience of carotid artery stenting for carotid artery stenosis. Ann Ital Chir. 2016;87:502-508. 8. Mazzaccaro D, Stegher S, Occhiuto MT, Malacrida G, Caldana M, Tealdi DG, et al. Treatment of significant carotid artery stenosis in 1824 patients. J Cardiovasc Surg. 2015;56:107-118. 9. Kolos I, Troitskiy A, Balakhonova T, Shariya M, Skrypnik D, Tvorogova T, et al. Modern medical treatment with or without carotid endarterectomy for severe asymptomatic carotid atherosclerosis. J Vasc Surg. 2015;62:914-922.
106: 980, OCTOBER 2017 WORLD NEUROSURGERY
LETTER: quality of intensive medical therapy (IMT) for asymptomatic T hecarotid stenosis (ACS) has improved greatly over the years, and some experts currently consider IMT for ACS as effective as surgical revascularization in reducing the risk of stroke.1,2 The “IMT-alone” concept, however, has some bias due to the lack of standardization, even in presence of solid benchmarks. For example, there is still no accord on the optimal drugs for blood pressure control and lipid lowering. Even antiplatelet therapy is not yet standardized. Moreover, Park et al.3 reported that during a mean follow-up of 49 months, the incidence of carotid stenosis progression in 129 patients with asymptomatic moderate ACS was high, despite the use of aspirin and statin. Finally, many patients in the real world don’t adhere to therapy because of a poor compliance and/or side effects.4 An ACS in a healthy patient may probably cause a lower risk of stroke compared with an ACS in a patient with a history of smoke, diabetes, hypertension, and dyslipidemia. Or maybe not? This should be still demonstrated. Actually, a subgroup of ACS with higher risk of stroke could be identified, based on specific features. For example, asymptomatic embolism assessed by transcranial Doppler5 and features of carotid plaque morphology (such as ulcerations and intraplaque hemorrhage) could contribute to increase the risk of stroke.6 This subgroup of patients may benefit from a surgical revascularization rather than IMT alone. Furthermore, some “real-world” experiences in the literature coming from high-volume centers with a long-term follow-up suggest that both carotid endarterectomy (CEA) and carotid artery stenting could be performed with a periprocedural neurologic risk lower than 1%.7 Also, in our experience, we observed a greater risk of death and stroke at 1 year in both symptomatic and asymptomatic patients who were treated using IMT alone.8 Eventually, a recent trial comparing CEA associated with IMT against IMT alone was stopped and judged to be unethical
980
www.SCIENCEDIRECT.com
because there was a demonstrated overwhelming superiority of CEA þ IMT in protecting patients from stroke and death, during a median follow-up of 3.3 years.9 Stronger evidence is needed to bring light in the shadows. While we wait, the application of respective national guidelines is mandatory, and the best therapy should be customized to each patient. Daniela Mazzaccaro1, Giovanni Romagnoni1, Alberto Maria Settembrini1, Giovanni Nano1,2 From the 1First Unit of Vascular Surgery, IRCCS Policlinico San Donato, San Donato Milanese, Milan; and 2Department of Biomedical Sciences for Health, University of Milan, Milan, Italy To whom correspondence should be addressed: Daniela Mazzaccaro, M.D. [E-mail: [email protected]; [email protected]] http://dx.doi.org/10.1016/j.wneu.2017.07.116.
REFERENCES 1. Abbott AL. Medical (nonsurgical) intervention alone is now best for prevention of stroke associated with asymptomatic severe carotid stenosis: results of a systematic review and analysis. Stroke. 2009;40:e573-e583. 2. Spence JD. Asymptomatic carotid stenosis. Circulation. 2013;127:739-742. 3. Park YJ, Kim DI, Kim GM, Kim DK, Kim YW. Natural history of asymptomatic moderate carotid artery stenosis in the era of medical therapy. World Neurosurg. 2016;91:247-253. 4. Naderi SH, Bestwick JP, Wald DS. Adherence to drugs that prevent cardiovascular disease: meta-analysis on 376,162 patients. Am J Med. 2012;125:882-887.e1. 5. Spence JD, Coates V, Li H, Tamayo A, Muñoz C, Hackam DG, et al. Effects of intensive medical therapy on microemboli and cardiovascular risk in asymptomatic carotid stenosis. Arch Neurol. 2010;167:180-186. 6. Huibers A, de Borst GJ, Bulbulia R, Pan H, Halliday A, ACST-1 collaborative group. Plaque echolucency and the risk of ischaemic stroke in patients with asymptomatic carotid stenosis within the First Asymptomatic Carotid Surgery Trial (ACST-1). Eur J Vasc Endovasc Surg. 2016;51:616-621. 7. Nano G, Stegher S, Occhiuto MT, Muzzarelli L, Malacrida G, Mazzaccaro DP. A 16-year experience of carotid artery stenting for carotid artery stenosis. Ann Ital Chir. 2016;87:502-508. 8. Mazzaccaro D, Stegher S, Occhiuto MT, Malacrida G, Caldana M, Tealdi DG, et al. Treatment of significant carotid artery stenosis in 1824 patients. J Cardiovasc Surg. 2015;56:107-118. 9. Kolos I, Troitskiy A, Balakhonova T, Shariya M, Skrypnik D, Tvorogova T, et al. Modern medical treatment with or without carotid endarterectomy for severe asymptomatic carotid atherosclerosis. J Vasc Surg. 2015;62:914-922.
106: 980, OCTOBER 2017 WORLD NEUROSURGERY