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Updated AAN Recommendations on Carotid Endarterectomy

The recommendations address many, though not all, of the issues facing endarterectomy practitioners today.

In this consensus report, the Therapeutics and Technology Assessment subcommittee of the AAN evaluated the literature on carotid endarterectomy (CE) published since the 1990 consensus report and addressed key issues related to the use of this commonly performed vascular surgery procedure.

The group concludes that CE is clearly effective for patients with symptomatic 70% to 99% carotid stenosis but should not be considered for patients with <50% stenosis. For patients with symptomatic 50% to 69% stenosis, the decision to perform CE should be individualized, based on clinical and angiographic variables; for example, it is unclear whether women with symptomatic 50% to 69% stenosis benefit from CE. The group recommends that patients aged 40 to 75 with asymptomatic 60% to 99% stenosis be considered for CE if they are relatively healthy and if the combined perioperative risk for stroke or death is below 3%.

Other recommendations include the use of aspirin (either 81 or 325 mg daily) before surgery and for at least 3 months afterward, the performance of CE within 2 weeks after a TIA or mild stroke (if possible), and careful assessment of radiologic variables such as contralateral carotid occlusion and ipsilateral near-occlusion in determining the risk-benefit ratio for CE. Suggestions for future research include continuing to evaluate CE versus carotid stenting in clinical trials; evaluating how cerebral hemodynamics affect the risk-benefit ratio of these procedures; and comparing outcomes with combined aggressive medical therapy, with CE, and with stenting, especially in the 50%- to 69%-stenosis population.

Comment: The trials evaluated for this review have greatly affected clinical practice regarding stroke-prevention decisions. The AAN subcommittee ably reviewed the literature concerning this important and timely topic. The recommendations are similar to those of other experts but provide the advantage of the well-established AAN subcommittee process and evidence-grading approach (N Engl J Med 2001; 345:1113 and Stroke 2003; 34:2767). The lack of a recommendation regarding CE versus carotid stenting was a disappointment. Many physicians suggest carotid stenting for low-risk patients even though there is no evidence that it is equivalent to CE. Another area that should have been addressed is what vascular imaging should be done before CE to confirm the percent stenosis. In the NASCET and ECST symptomatic trials, catheter-based angiography was required, but in the ACST trial, carotid ultrasonography was used by itself to determine the percent stenosis. Many centers currently use ultrasonography and a confirmatory noninvasive technology, either contrast or noncontrast MR angiography or CT angiography (Neurology 2004; 62:1282 and Stroke 2004; 35:2306). Despite these concerns, this review provides clear, concise information and recommendations that will be very useful to all physicians who face decisions about recommending for or against CE.

— Marc Fisher, MD

Dr. Fisher is Professor of Neurology, University of Massachusetts Medical School, Worcester.

Published in Journal Watch Neurology December 29, 2005

Citation(s):

Chaturvedi S et al. Carotid endarterectomy — An evidence-based review: Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 2005 Sep 27; 65:794-801.

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