Natural History of Non-operative Management in Asymptomatic Patients with 70%–80% Internal Carotid Artery Stenosis by Duplex Criteria. (September 2020)

• Record Type: Journal Article
• Authors: Cheng, Thomas W.; Pointer, Keyona E.; Gopal, Mallika; Farber, Alik; Jones, Douglas W.; Eberhardt, Robert T.; Kalish, Jeffrey A.; Eslami, Mohammad H.; Rybin, Denis; Siracuse, Jeffrey J.
• Is Part Of: European journal of vascular and endovascular surgery. Volume 60:Number 3(2020)
• Page Start: 339
• Page End: 346
• Publication Date: 2020-09
• Subjects: Asymptomatic -- Carotid -- Medical therapy -- Non-operative management -- Vascular surgery; Blood-vessels -- Endoscopic surgery -- Periodicals; Blood-vessels -- Surgery -- Periodicals; Vascular Surgical Procedures -- Periodicals; Vascular Surgical Procedures -- methods -- Periodicals; Vaisseaux sanguins -- Chirurgie -- Périodiques; Vaisseaux sanguins -- Chirurgie endoscopique -- Périodiques; Blood-vessels -- Endoscopic surgery; Blood-vessels -- Surgery; Endoscopy; Electronic journals; Periodicals; Electronic journals; 617.413005
• DOI: 10.1016/j.ejvs.2020.05.039
• Languages: English
• ISSNs: 1078-5884

Abstract

Abstract : Objective: Treatment of asymptomatic internal carotid artery (ICA) stenosis, particularly for moderate to severe (70%–80%) disease, is controversial. The goal was to assess the clinical course of patients with moderate to severe carotid stenosis. Methods: A single institution retrospective analysis of patients with asymptomatic ICA stenosis identified on duplex ultrasound as moderate to severe (70%–80%) from 2003 to 2018 were analysed. Duplex criteria for 70%–80% stenosis was a systolic velocity of ≥325 cm/s or an ICA:common carotid artery ratio of ≥4, and an end diastolic velocity of <140 cm/s. Asymptomatic status was defined as no stroke/transient ischaemic attack (TIA) within six months of index duplex. Primary outcomes were progression of stenosis to >80%, ipsilateral stroke/TIA without documented progression, and death. Results: In total, 206 carotid arteries were identified in 182 patients meeting the inclusion criteria. Mean patient age was 71.5 years, 57.7% were male, and 67% were white. There were 19 stenoses removed from analysis except for survival analysis as they initially underwent carotid endarterectomy or carotid artery stent based on surgeon/patient preference. Documented progression occurred in 24.1% of stenoses. There were 5.3% of stenoses associated with an ipsilateral stroke/TIA without documented progression, which occurred at a mean of 26.4 months. Kaplan–Meier analysis demonstrated a 60.3% five year freedom from stenosis progression, 92.5% five year freedom from stroke/TIA without documented progression, and 83.7% five year survival. Risk factors associated with stroke/TIA without documented progression at five years were atrial fibrillation (hazard ratio [HR] 14.87, 95% confidence interval [CI] 2.72–81.16; p = .002) and clopidogrel use at index duplex (HR 6.19, 95% CI 1.33–28.83; p = .020). Risk factors associated with death at five years were end stage renal disease (HR 9.67, 95% CI 2.05–45.6; p = .004), atrial fibrillation (HR 7.55, 95% CI 2.48–23; p < .001), prior head/neck radiation (HR 6.37, 95% CI 1.39–29.31; p = .017), non-obese patients (HR 5.49, 95% CI 1.52–20; p = .009), and non-aspirin use at index duplex (HR 3.05, 95% CI 1.12–8.33; p = .030). Conclusion: Patients with asymptomatic moderate to severe carotid stenosis had a low rate of stroke/TIA without documented progression. However, there was a high rate of stenosis progression reinforcing the need to follow these patients closely.