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*It is only for medical professionals to read for reference.
It is recommended to conduct a comprehensive assessment based on the patient's own situation.
Cerebrovascular disease is the disease with the highest mortality and disability rate in my country.
Its rapid onset and slow recovery are serious to the patient's family and the entire society.
Economic burden.
Among them, ischemic stroke caused by carotid artery stenosis accounts for 60%-65% of all cerebrovascular diseases, and has become one of the "top killers" that endanger people's health in today's society.
On the morning of March 19, US Central Time, the 2021 International Stroke Conference (ISC) invited four leading academics, Anne Abbott, Randolph Marshall, Saeid Shahidi, and Wesley Moore, to discuss whether carotid artery stenosis is a radical treatment or conservative observation This topic of everyone's attention has been intensely debated.
Figure 1: The four professors who participated in the discussion 01 Carotid artery stenosis should be carried out and risk stratification Professor Anne Abbot and Professor Randolph Marshall introduced the degree of carotid artery stenosis should be measured and risk stratification.
▌ Degree stratification Currently, European Carotid Surgery Trial (ECST) and North American Symptomatic Carotid Endarterectomy Trail (NASCET) are still used internationally for the degree of stenosis.
1.
ECST method ECST method stenosis = (1-the width of the narrowest part of the internal carotid artery/the simulated internal diameter of the carotid artery enlargement is the basic internal diameter) × 100%.
The degree of stenosis of ECST is divided into 4 levels, mild stenosis: <30%; moderate stenosis: 30%-69%; severe stenosis: 70%-99%; complete occlusion: stenosis measured by the state before occlusion>99%.
2.
NASCET method NASCET method stenosis = (1-the width of the narrowest part of the internal carotid artery / the basic inner diameter of the neck enlargement) × 100%.
Figure 2: Schematic diagram of the ECST method and the NASCET method ▌ Risk stratification Risk factors stratification for carotid artery stenosis include old age, men, high blood pressure, smoking, dyslipidemia, diabetes, and heart disease.
02 Asymptomatic carotid stenosis, conservative treatment is recommended.
Professor Wesley Moore listed several studies in recent years that support patients with asymptomatic carotid stenosis and recommend conservative treatment.
The NASCET test describes the relationship between the degree of carotid artery stenosis and the risk of stroke.
The enrolled patients with carotid artery stenosis were treated with medical drugs for 18 months, and the results showed that the risk of stroke was 19% for patients with stenosis of 70%-79%, and the risk of stroke for patients with stenosis of 80%-89% was 28%.
, The risk of stroke is 33% for patients with stenosis of 90%-99%.
Asymptomatic Carotid Surgery Trial (ACST) showed that patients with stenosis greater than 70%, given medication, the risk of stroke was significantly reduced.
Although the trial also proved the significance of carotid endarteretomy (CEA) in the treatment of carotid artery stenosis, there was no significant difference between groups compared with drug therapy.
Therefore, for patients with carotid artery stenosis, treatment should be combined with the patient's individual conditions (risk factors, life expectancy, etc.
).
It is recommended that patients with asymptomatic carotid artery stenosis should be treated with drugs as the first choice.
03 Screening for asymptomatic carotid artery stenosis is harmful and not beneficial.
Figure 3: 2021 JAMA latest research Professor Randolph Marshall introduced the latest research published on JAMA in 2021, which reconfirmed the recommendation of USPTF (US Preventive Services Task Force) in 2014 Opinion, that is, routine screening is not recommended for asymptomatic carotid stenosis, especially for low-risk groups. The population attributable risk of asymptomatic carotid artery stenosis-related stroke is about 0.
7%, which is much lower than other risk factors for stroke, including high blood pressure, smoking, dyslipidemia, diabetes, and heart disease.
There is currently no trial to prove that the benefits of interventions for asymptomatic carotid artery stenosis outweigh other risk subgroups.
Therefore, routine screening is not considered for patients with asymptomatic carotid artery stenosis.
04 Symptomatic carotid artery stenosis should be selected for appropriate surgical treatment Figure 4: Professor PPTSaeid Shahidi introduced a meta-analysis of carotid artery stent (CAS) and CEA comparative trials.
It turns out that compared with CAS, CEA has better safety and applicability.
Professor Saeid Shahidi emphasized that at present, the surgical method should be selected reasonably according to the patient’s comprehensive situation.
Patients with low surgical risk should first consider CEA.
For patients with high risk of CEA or patients with restenosis after CEA, CAS treatment should be recommended first to avoid the high risk of CEA.
The second operation is difficult.
Summary: The treatment of carotid artery stenosis is an important issue that clinicians pay attention to.
We must conduct a comprehensive assessment based on the patient's own situation, focusing on the degree of carotid artery stenosis and patient risk stratification, weigh the benefits and risks of treatment, and formulate a reasonable treatment plan for the patient.
Reference materials: [1] Goldstein LB, et al.
Screening for Asymptomatic Carotid Artery Stenosis: Lack of Clinical Benefit, Potential for Harm.
JAMA 2021 02 02; 325 (5) [2] Keran WN, et al.
Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.
Stroke, 2014, 45: 2160-2236.
[3] The treatment of extracranial carotid artery stenosis refers to clinical practice in China Doctor’s Journal, 2009, 37, 63-66 [4] Chinese Medical Association Surgery Branch, Guidelines for Diagnosis and Treatment of Carotid Artery Stenosis.
Chinese Journal of Vascular Surgery, 2017, 9(9): 169-175.
It is recommended to conduct a comprehensive assessment based on the patient's own situation.
Cerebrovascular disease is the disease with the highest mortality and disability rate in my country.
Its rapid onset and slow recovery are serious to the patient's family and the entire society.
Economic burden.
Among them, ischemic stroke caused by carotid artery stenosis accounts for 60%-65% of all cerebrovascular diseases, and has become one of the "top killers" that endanger people's health in today's society.
On the morning of March 19, US Central Time, the 2021 International Stroke Conference (ISC) invited four leading academics, Anne Abbott, Randolph Marshall, Saeid Shahidi, and Wesley Moore, to discuss whether carotid artery stenosis is a radical treatment or conservative observation This topic of everyone's attention has been intensely debated.
Figure 1: The four professors who participated in the discussion 01 Carotid artery stenosis should be carried out and risk stratification Professor Anne Abbot and Professor Randolph Marshall introduced the degree of carotid artery stenosis should be measured and risk stratification.
▌ Degree stratification Currently, European Carotid Surgery Trial (ECST) and North American Symptomatic Carotid Endarterectomy Trail (NASCET) are still used internationally for the degree of stenosis.
1.
ECST method ECST method stenosis = (1-the width of the narrowest part of the internal carotid artery/the simulated internal diameter of the carotid artery enlargement is the basic internal diameter) × 100%.
The degree of stenosis of ECST is divided into 4 levels, mild stenosis: <30%; moderate stenosis: 30%-69%; severe stenosis: 70%-99%; complete occlusion: stenosis measured by the state before occlusion>99%.
2.
NASCET method NASCET method stenosis = (1-the width of the narrowest part of the internal carotid artery / the basic inner diameter of the neck enlargement) × 100%.
Figure 2: Schematic diagram of the ECST method and the NASCET method ▌ Risk stratification Risk factors stratification for carotid artery stenosis include old age, men, high blood pressure, smoking, dyslipidemia, diabetes, and heart disease.
02 Asymptomatic carotid stenosis, conservative treatment is recommended.
Professor Wesley Moore listed several studies in recent years that support patients with asymptomatic carotid stenosis and recommend conservative treatment.
The NASCET test describes the relationship between the degree of carotid artery stenosis and the risk of stroke.
The enrolled patients with carotid artery stenosis were treated with medical drugs for 18 months, and the results showed that the risk of stroke was 19% for patients with stenosis of 70%-79%, and the risk of stroke for patients with stenosis of 80%-89% was 28%.
, The risk of stroke is 33% for patients with stenosis of 90%-99%.
Asymptomatic Carotid Surgery Trial (ACST) showed that patients with stenosis greater than 70%, given medication, the risk of stroke was significantly reduced.
Although the trial also proved the significance of carotid endarteretomy (CEA) in the treatment of carotid artery stenosis, there was no significant difference between groups compared with drug therapy.
Therefore, for patients with carotid artery stenosis, treatment should be combined with the patient's individual conditions (risk factors, life expectancy, etc.
).
It is recommended that patients with asymptomatic carotid artery stenosis should be treated with drugs as the first choice.
03 Screening for asymptomatic carotid artery stenosis is harmful and not beneficial.
Figure 3: 2021 JAMA latest research Professor Randolph Marshall introduced the latest research published on JAMA in 2021, which reconfirmed the recommendation of USPTF (US Preventive Services Task Force) in 2014 Opinion, that is, routine screening is not recommended for asymptomatic carotid stenosis, especially for low-risk groups. The population attributable risk of asymptomatic carotid artery stenosis-related stroke is about 0.
7%, which is much lower than other risk factors for stroke, including high blood pressure, smoking, dyslipidemia, diabetes, and heart disease.
There is currently no trial to prove that the benefits of interventions for asymptomatic carotid artery stenosis outweigh other risk subgroups.
Therefore, routine screening is not considered for patients with asymptomatic carotid artery stenosis.
04 Symptomatic carotid artery stenosis should be selected for appropriate surgical treatment Figure 4: Professor PPTSaeid Shahidi introduced a meta-analysis of carotid artery stent (CAS) and CEA comparative trials.
It turns out that compared with CAS, CEA has better safety and applicability.
Professor Saeid Shahidi emphasized that at present, the surgical method should be selected reasonably according to the patient’s comprehensive situation.
Patients with low surgical risk should first consider CEA.
For patients with high risk of CEA or patients with restenosis after CEA, CAS treatment should be recommended first to avoid the high risk of CEA.
The second operation is difficult.
Summary: The treatment of carotid artery stenosis is an important issue that clinicians pay attention to.
We must conduct a comprehensive assessment based on the patient's own situation, focusing on the degree of carotid artery stenosis and patient risk stratification, weigh the benefits and risks of treatment, and formulate a reasonable treatment plan for the patient.
Reference materials: [1] Goldstein LB, et al.
Screening for Asymptomatic Carotid Artery Stenosis: Lack of Clinical Benefit, Potential for Harm.
JAMA 2021 02 02; 325 (5) [2] Keran WN, et al.
Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.
Stroke, 2014, 45: 2160-2236.
[3] The treatment of extracranial carotid artery stenosis refers to clinical practice in China Doctor’s Journal, 2009, 37, 63-66 [4] Chinese Medical Association Surgery Branch, Guidelines for Diagnosis and Treatment of Carotid Artery Stenosis.
Chinese Journal of Vascular Surgery, 2017, 9(9): 169-175.
