SVS Guidelines for Management of Extracranial Cerebrovascular Disease

In June 2021, the Society for Vascular Surgery (SVS) published clinical practice guidelines for management of extracranial cerebrovascular disease.^[26]Recommendations included the following:

Carotid endarterectomy (CEA) is recommended as first-line treatment for symptomatic low-risk surgical patients with stenosis of 50-99% and asymptomatic patients with stenosis of 70-99%.
Carotid revascularization is appropriate for symptomatic patients with recent stable stroke and >50% stenosis. It should be performed as soon as the patient is neurologically stable (after 48 hr but before 14 d from symptom onset).
Screening for clinically asymptomatic carotid artery stenosis in patients without symptoms or risk factors for carotid artery disease is not recommended.
In selected asymptomatic patients at increased risk for carotid stenosis, screening for clinically asymptomatic carotid artery stenosis is suggested, as long as the patients are potentially fit for and willing to consider carotid intervention upon discovery of significant stenosis.
In patients with symptomatic carotid stenosis of 50-99% who require both CEA and coronary artery bypass grafting (CABG), CEA before or concomitant with CABG is suggested.

Medication

North American Symptomatic Carotid Endarterectomy Trial Collaborators., Barnett HJM, Taylor DW, Haynes RB, Sackett DL, Peerless SJ, et al. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med. 1991 Aug 15. 325 (7):445-53. [QxMD MEDLINE Link].
Stroke facts. Centers for Disease Control and Prevention. Available at https://www.cdc.gov/stroke/facts.htm. October 14, 2022; Accessed: March 22, 2023.
Young B, Moore WS, Robertson JT, Toole JF, Ernst CB, Cohen SN, et al. An analysis of perioperative surgical mortality and morbidity in the asymptomatic carotid atherosclerosis study. ACAS Investigators. Asymptomatic Carotid Atherosclerosis Study. Stroke. 1996 Dec. 27 (12):2216-24. [QxMD MEDLINE Link].
Mas JL, Trinquart L, Leys D, Albucher JF, Rousseau H, Viguier A, et al. Endarterectomy Versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis (EVA-3S) trial: results up to 4 years from a randomised, multicentre trial. Lancet Neurol. 2008 Oct. 7 (10):885-92. [QxMD MEDLINE Link].
Wiesmann M, Schöpf V, Jansen O, Brückmann H. Stent-protected angioplasty versus carotid endarterectomy in patients with carotid artery stenosis: meta-analysis of randomized trial data. Eur Radiol. 2008 Dec. 18 (12):2956-66. [QxMD MEDLINE Link].
Meier P, Knapp G, Tamhane U, Chaturvedi S, Gurm HS. Short term and intermediate term comparison of endarterectomy versus stenting for carotid artery stenosis: systematic review and meta-analysis of randomised controlled clinical trials. BMJ. 2010 Feb 12. 340:c467. [QxMD MEDLINE Link]. [Full Text].
Gurm HS, Yadav JS, Fayad P, Katzen BT, Mishkel GJ, Bajwa TK, et al. Long-term results of carotid stenting versus endarterectomy in high-risk patients. N Engl J Med. 2008 Apr 10. 358 (15):1572-9. [QxMD MEDLINE Link]. [Full Text].
Illuminati G, Ricco JB, Caliò F, Pacilè MA, Miraldi F, Frati G, et al. Short-term results of a randomized trial examining timing of carotid endarterectomy in patients with severe asymptomatic unilateral carotid stenosis undergoing coronary artery bypass grafting. J Vasc Surg. 2011 Oct. 54 (4):993-9; discussion 998-9. [QxMD MEDLINE Link].
Brown K, Itum DS, Preiss J, Duwayri Y, Veeraswamy RK, Salam A, et al. Carotid artery stenting has increased risk of external carotid artery occlusion compared with carotid endarterectomy. J Vasc Surg. 2015 Jan. 61 (1):119-24. [QxMD MEDLINE Link].
Brott TG, Hobson RW 2nd, Howard G, Roubin GS, Clark WM, Brooks W, et al. Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med. 2010 Jul 1. 363 (1):11-23. [QxMD MEDLINE Link]. [Full Text].
Hill MD, Brooks W, Mackey A, Clark WM, Meschia JF, Morrish WF, et al. Stroke after carotid stenting and endarterectomy in the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST). Circulation. 2012 Dec 18. 126 (25):3054-61. [QxMD MEDLINE Link].
Hye RJ, Mackey A, Hill MD, Voeks JH, Cohen DJ, Wang K, et al. Incidence, outcomes, and effect on quality of life of cranial nerve injury in the Carotid Revascularization Endarterectomy versus Stenting Trial. J Vasc Surg. 2015 May. 61 (5):1208-14. [QxMD MEDLINE Link].
Brott TG, Calvet D, Howard G, Gregson J, Algra A, Becquemin JP, et al. Long-term outcomes of stenting and endarterectomy for symptomatic carotid stenosis: a preplanned pooled analysis of individual patient data. Lancet Neurol. 2019 Apr. 18 (4):348-356. [QxMD MEDLINE Link].
Naazie IN, Magee GA, Mathlouthi A, Elsayed N, Dakour-Aridi H, Malas MB. Primary mechanism of stroke reduction in transcarotid artery revascularization is dynamic flow reversal. J Vasc Surg. 2021 Jul. 74 (1):187-194. [QxMD MEDLINE Link].
Kwolek CJ, Jaff MR, Leal JI, Hopkins LN, Shah RM, Hanover TM, et al. Results of the ROADSTER multicenter trial of transcarotid stenting with dynamic flow reversal. J Vasc Surg. 2015 Nov. 62 (5):1227-34. [QxMD MEDLINE Link].
Malas MB, Leal Lorenzo JI, Nejim B, Hanover TM, Mehta M, Kashyap V, et al. Analysis of the ROADSTER pivotal and extended-access cohorts shows excellent 1-year durability of transcarotid stenting with dynamic flow reversal. J Vasc Surg. 2019 Jun. 69 (6):1786-1796. [QxMD MEDLINE Link].
Schermerhorn ML, Liang P, Dakour-Aridi H, Kashyap VS, Wang GJ, Nolan BW, et al. In-hospital outcomes of transcarotid artery revascularization and carotid endarterectomy in the Society for Vascular Surgery Vascular Quality Initiative. J Vasc Surg. 2020 Jan. 71 (1):87-95. [QxMD MEDLINE Link].
Malas MB, Dakour-Aridi H, Wang GJ, Kashyap VS, Motaganahalli RL, Eldrup-Jorgensen J, et al. Transcarotid artery revascularization versus transfemoral carotid artery stenting in the Society for Vascular Surgery Vascular Quality Initiative. J Vasc Surg. 2019 Jan. 69 (1):92-103.e2. [QxMD MEDLINE Link].
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van Engelen A, Wannarong T, Parraga G, Niessen WJ, Fenster A, Spence JD, et al. Three-dimensional carotid ultrasound plaque texture predicts vascular events. Stroke. 2014 Sep. 45 (9):2695-701. [QxMD MEDLINE Link].
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Kato T, Sakai H, Takagi T, Nishimura Y. Cilostazol prevents progression of asymptomatic carotid artery stenosis in patients with contralateral carotid artery stenting. AJNR Am J Neuroradiol. 2012 Aug. 33 (7):1262-6. [QxMD MEDLINE Link].
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[Guideline] AbuRahma AF, Avgerinos ED, Chang RW, Darling RC 3rd, Duncan AA, Forbes TL, et al. Society for Vascular Surgery clinical practice guidelines for management of extracranial cerebrovascular disease. J Vasc Surg. 2022 Jan. 75 (1S):4S-22S. [QxMD MEDLINE Link].
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Media Gallery

Arteriogram of aortic arch and its branches.
Arteriogram of carotid stenosis.
Atherosclerotic plaque removed at time of carotid endarterectomy (areas of ulceration with thrombus and intraplaque hemorrhage are present).
Carotid artery exposed prior to carotid endarterectomy (coil present in internal carotid artery).
Carotid artery following endarterectomy and prior to closure (tapered endpoint and smooth appearance of lumen).
Carotid artery following Dacron patch angioplasty.
Selective left carotid angiogram.
Oblique view of left carotid artery demonstrating lesion within internal carotid artery.
Placement of stent into internal carotid artery. Note filter wire in upper photos (dots at top of internal carotid artery).
Angioplasty after stent placement; again, note filter wire protecting distal carotid artery.
Completion arteriogram displaying improvement in diameter of internal carotid artery.
Normal carotid arteries on color flow duplex ultrasonography.
Color flow duplex ultrasonogram reveals 80-99% left carotid stenosis and normal right carotid.
Carotid plaque.

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Author

Jake F Hemingway, MD Resident Physician in Integrated Vascular Surgery, Department of Surgery, University of Washington School of Medicine

Jake F Hemingway, MD is a member of the following medical societies: Society for Vascular Surgery

Disclosure: Nothing to disclose.

Coauthor(s)

Niten Singh, MD, FACS Associate Professor of Surgery, University of Washington School of Medicine; Director of Vascular Limb Preservation, Vascular Surgery Clinic at Harborview

Niten Singh, MD, FACS is a member of the following medical societies: American College of Surgeons, American Medical Association, Society for Vascular Surgery

Disclosure: Nothing to disclose.

Chief Editor

Vincent Lopez Rowe, MD, FACS Professor and Chief, Division of Vascular and Endovascular Surgery, Gonda (Goldschmied) Vascular Center, University of California, Los Angeles, David Geffen School of Medicine

Vincent Lopez Rowe, MD, FACS is a member of the following medical societies: American College of Surgeons, American Heart Association, American Surgical Association, Pacific Coast Surgical Association, Society for Clinical Vascular Surgery, Society for Vascular Surgery, Society of Black Academic Surgeons, Society of Black Vascular Surgeons, Southern California Vascular Surgical Society, Western Vascular Society

Disclosure: Nothing to disclose.

Additional Contributors

April L Rodriguez, MD, MS Senior Resident, Integrated Vascular Surgery Residency, Department of Surgery, University of Washington School of Medicine

April L Rodriguez, MD, MS is a member of the following medical societies: American College of Surgeons, Society for Clinical Vascular Surgery, Vascular and Endovascular Surgery Society

Disclosure: Nothing to disclose.

Acknowledgements

David L Gillespie, MD, FACS, RVT, DMCC, COL, MC USA Chief and Program Director, Vascular Surgery Service, Walter Reed Army Medical Center; Professor of Surgery, Uniformed Services University of the Health Sciences; Vascular Surgery Consultant, Office of the US Army Surgeon General

David L Gillespie, MD, FACS, RVT, DMCC, COL, MC is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Venous Forum, Eastern Vascular Society, Society for Vascular Surgery, and Southern Association for Vascular Surgery

Disclosure: Nothing to disclose.

James M Goff, MD Assistant Chief, Department of Surgery, Walter Reed Army Medical Center; Assistant Professor, F Department of Surgery, F Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences

James M Goff, MD is a member of the following medical societies: American College of Surgeons

Disclosure: Nothing to disclose.

Sean D O'Donnell, MD Director, Department of Surgery, Section of Vascular and Endovascular Surgery, Washington Hospital Center

Sean D O'Donnell, MD is a member of the following medical societies: American College of Surgeons and Association of Military Surgeons of the US

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Sections Atherosclerotic Disease of the Carotid Artery
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Atherosclerotic Disease of the Carotid Artery Guidelines

SVS Guidelines for Management of Extracranial Cerebrovascular Disease

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