Systematic review of guidelines for the management of asymptomatic and symptomatic carotid stenosis

Anne Abbott, Kosmas Ioannis Paraskevas, Stavros K Kakkos, Jonathan Golledge, Hans-Henning Eckstein, Larry J Diaz-Sandoval, Longxing Cao, Qiang Fu, Tissa Wijeratne, Thomas W H Leung, Miguel Montero-Baker, Byung-Chul Lee, Sabine Pircher, Marije Caroline Bosch, Martine Neeltje Dennekamp, Peter Ringleb

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Abstract

Background and Purpose-We systematically compared and appraised contemporary guidelines on management of asymptomatic and symptomatic carotid artery stenosis. Methods-We systematically searched for guideline recommendations on carotid endarterectomy (CEA) or carotid angioplasty/stenting (CAS) published in any language between January 1, 2008, and January 28, 2015. Only the latest guideline per writing group was selected. Each guideline was analyzed independently by 2 to 6 authors to determine clinical scenarios covered, recommendations given, and scientific evidence used. Results-Thirty-four eligible guidelines were identified from 23 different regions/countries in 6 languages. Of 28 guidelines with asymptomatic carotid artery stenosis procedural recommendations, 24 (86 ) endorsed CEA (recommended it should or may be provided) for ?50 to 99 average-surgical-risk asymptomatic carotid artery stenosis, 17 (61 ) endorsed CAS, 8 (29 ) opposed CAS, and 1 (4 ) endorsed medical treatment alone. For asymptomatic carotid artery stenosis patients considered high-CEA-risk because of comorbidities, vascular anatomy, or undefined reasons, CAS was endorsed in 13 guidelines (46 ). Thirty-one of 33 guidelines (94 ) with symptomatic carotid artery stenosis procedural recommendations endorsed CEA for patients with ?50 to 99 average-CEA-risk symptomatic carotid artery stenosis, 19 (58 ) endorsed CAS and 9 (27 ) opposed CAS. For high-CEA-risk symptomatic carotid artery stenosis because of comorbidities, vascular anatomy, or undefined reasons, CAS was endorsed in 27 guidelines (82 ). Guideline procedural recommendations were based only on results of trials in which patients were randomized 12 to 34 years ago, rarely reflected medical treatment improvements and often understated potential CAS hazards. Qualifying terminology summarizing recommendations or evidence lacked standardization, impeding guideline interpretation, and comparison. Conclusions-This systematic review has identified many opportunities to modernize and otherwise improve carotid stenosis management guidelines.
Original languageEnglish
Pages (from-to)3288 - 3301
Number of pages14
JournalStroke
Volume46
Issue number11
DOIs
Publication statusPublished - 2015

Cite this

Abbott, A., Paraskevas, K. I., Kakkos, S. K., Golledge, J., Eckstein, H-H., Diaz-Sandoval, L. J., ... Ringleb, P. (2015). Systematic review of guidelines for the management of asymptomatic and symptomatic carotid stenosis. Stroke, 46(11), 3288 - 3301. https://doi.org/10.1161/STROKEAHA.115.003390
Abbott, Anne ; Paraskevas, Kosmas Ioannis ; Kakkos, Stavros K ; Golledge, Jonathan ; Eckstein, Hans-Henning ; Diaz-Sandoval, Larry J ; Cao, Longxing ; Fu, Qiang ; Wijeratne, Tissa ; Leung, Thomas W H ; Montero-Baker, Miguel ; Lee, Byung-Chul ; Pircher, Sabine ; Bosch, Marije Caroline ; Dennekamp, Martine Neeltje ; Ringleb, Peter. / Systematic review of guidelines for the management of asymptomatic and symptomatic carotid stenosis. In: Stroke. 2015 ; Vol. 46, No. 11. pp. 3288 - 3301.
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abstract = "Background and Purpose-We systematically compared and appraised contemporary guidelines on management of asymptomatic and symptomatic carotid artery stenosis. Methods-We systematically searched for guideline recommendations on carotid endarterectomy (CEA) or carotid angioplasty/stenting (CAS) published in any language between January 1, 2008, and January 28, 2015. Only the latest guideline per writing group was selected. Each guideline was analyzed independently by 2 to 6 authors to determine clinical scenarios covered, recommendations given, and scientific evidence used. Results-Thirty-four eligible guidelines were identified from 23 different regions/countries in 6 languages. Of 28 guidelines with asymptomatic carotid artery stenosis procedural recommendations, 24 (86 ) endorsed CEA (recommended it should or may be provided) for ?50 to 99 average-surgical-risk asymptomatic carotid artery stenosis, 17 (61 ) endorsed CAS, 8 (29 ) opposed CAS, and 1 (4 ) endorsed medical treatment alone. For asymptomatic carotid artery stenosis patients considered high-CEA-risk because of comorbidities, vascular anatomy, or undefined reasons, CAS was endorsed in 13 guidelines (46 ). Thirty-one of 33 guidelines (94 ) with symptomatic carotid artery stenosis procedural recommendations endorsed CEA for patients with ?50 to 99 average-CEA-risk symptomatic carotid artery stenosis, 19 (58 ) endorsed CAS and 9 (27 ) opposed CAS. For high-CEA-risk symptomatic carotid artery stenosis because of comorbidities, vascular anatomy, or undefined reasons, CAS was endorsed in 27 guidelines (82 ). Guideline procedural recommendations were based only on results of trials in which patients were randomized 12 to 34 years ago, rarely reflected medical treatment improvements and often understated potential CAS hazards. Qualifying terminology summarizing recommendations or evidence lacked standardization, impeding guideline interpretation, and comparison. Conclusions-This systematic review has identified many opportunities to modernize and otherwise improve carotid stenosis management guidelines.",
author = "Anne Abbott and Paraskevas, {Kosmas Ioannis} and Kakkos, {Stavros K} and Jonathan Golledge and Hans-Henning Eckstein and Diaz-Sandoval, {Larry J} and Longxing Cao and Qiang Fu and Tissa Wijeratne and Leung, {Thomas W H} and Miguel Montero-Baker and Byung-Chul Lee and Sabine Pircher and Bosch, {Marije Caroline} and Dennekamp, {Martine Neeltje} and Peter Ringleb",
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Abbott, A, Paraskevas, KI, Kakkos, SK, Golledge, J, Eckstein, H-H, Diaz-Sandoval, LJ, Cao, L, Fu, Q, Wijeratne, T, Leung, TWH, Montero-Baker, M, Lee, B-C, Pircher, S, Bosch, MC, Dennekamp, MN & Ringleb, P 2015, 'Systematic review of guidelines for the management of asymptomatic and symptomatic carotid stenosis', Stroke, vol. 46, no. 11, pp. 3288 - 3301. https://doi.org/10.1161/STROKEAHA.115.003390

Systematic review of guidelines for the management of asymptomatic and symptomatic carotid stenosis. / Abbott, Anne; Paraskevas, Kosmas Ioannis; Kakkos, Stavros K; Golledge, Jonathan; Eckstein, Hans-Henning; Diaz-Sandoval, Larry J; Cao, Longxing; Fu, Qiang; Wijeratne, Tissa; Leung, Thomas W H; Montero-Baker, Miguel; Lee, Byung-Chul; Pircher, Sabine; Bosch, Marije Caroline; Dennekamp, Martine Neeltje; Ringleb, Peter.

In: Stroke, Vol. 46, No. 11, 2015, p. 3288 - 3301.

Research output: Contribution to journalArticleResearchpeer-review

TY - JOUR

T1 - Systematic review of guidelines for the management of asymptomatic and symptomatic carotid stenosis

AU - Abbott, Anne

AU - Paraskevas, Kosmas Ioannis

AU - Kakkos, Stavros K

AU - Golledge, Jonathan

AU - Eckstein, Hans-Henning

AU - Diaz-Sandoval, Larry J

AU - Cao, Longxing

AU - Fu, Qiang

AU - Wijeratne, Tissa

AU - Leung, Thomas W H

AU - Montero-Baker, Miguel

AU - Lee, Byung-Chul

AU - Pircher, Sabine

AU - Bosch, Marije Caroline

AU - Dennekamp, Martine Neeltje

AU - Ringleb, Peter

PY - 2015

Y1 - 2015

N2 - Background and Purpose-We systematically compared and appraised contemporary guidelines on management of asymptomatic and symptomatic carotid artery stenosis. Methods-We systematically searched for guideline recommendations on carotid endarterectomy (CEA) or carotid angioplasty/stenting (CAS) published in any language between January 1, 2008, and January 28, 2015. Only the latest guideline per writing group was selected. Each guideline was analyzed independently by 2 to 6 authors to determine clinical scenarios covered, recommendations given, and scientific evidence used. Results-Thirty-four eligible guidelines were identified from 23 different regions/countries in 6 languages. Of 28 guidelines with asymptomatic carotid artery stenosis procedural recommendations, 24 (86 ) endorsed CEA (recommended it should or may be provided) for ?50 to 99 average-surgical-risk asymptomatic carotid artery stenosis, 17 (61 ) endorsed CAS, 8 (29 ) opposed CAS, and 1 (4 ) endorsed medical treatment alone. For asymptomatic carotid artery stenosis patients considered high-CEA-risk because of comorbidities, vascular anatomy, or undefined reasons, CAS was endorsed in 13 guidelines (46 ). Thirty-one of 33 guidelines (94 ) with symptomatic carotid artery stenosis procedural recommendations endorsed CEA for patients with ?50 to 99 average-CEA-risk symptomatic carotid artery stenosis, 19 (58 ) endorsed CAS and 9 (27 ) opposed CAS. For high-CEA-risk symptomatic carotid artery stenosis because of comorbidities, vascular anatomy, or undefined reasons, CAS was endorsed in 27 guidelines (82 ). Guideline procedural recommendations were based only on results of trials in which patients were randomized 12 to 34 years ago, rarely reflected medical treatment improvements and often understated potential CAS hazards. Qualifying terminology summarizing recommendations or evidence lacked standardization, impeding guideline interpretation, and comparison. Conclusions-This systematic review has identified many opportunities to modernize and otherwise improve carotid stenosis management guidelines.

AB - Background and Purpose-We systematically compared and appraised contemporary guidelines on management of asymptomatic and symptomatic carotid artery stenosis. Methods-We systematically searched for guideline recommendations on carotid endarterectomy (CEA) or carotid angioplasty/stenting (CAS) published in any language between January 1, 2008, and January 28, 2015. Only the latest guideline per writing group was selected. Each guideline was analyzed independently by 2 to 6 authors to determine clinical scenarios covered, recommendations given, and scientific evidence used. Results-Thirty-four eligible guidelines were identified from 23 different regions/countries in 6 languages. Of 28 guidelines with asymptomatic carotid artery stenosis procedural recommendations, 24 (86 ) endorsed CEA (recommended it should or may be provided) for ?50 to 99 average-surgical-risk asymptomatic carotid artery stenosis, 17 (61 ) endorsed CAS, 8 (29 ) opposed CAS, and 1 (4 ) endorsed medical treatment alone. For asymptomatic carotid artery stenosis patients considered high-CEA-risk because of comorbidities, vascular anatomy, or undefined reasons, CAS was endorsed in 13 guidelines (46 ). Thirty-one of 33 guidelines (94 ) with symptomatic carotid artery stenosis procedural recommendations endorsed CEA for patients with ?50 to 99 average-CEA-risk symptomatic carotid artery stenosis, 19 (58 ) endorsed CAS and 9 (27 ) opposed CAS. For high-CEA-risk symptomatic carotid artery stenosis because of comorbidities, vascular anatomy, or undefined reasons, CAS was endorsed in 27 guidelines (82 ). Guideline procedural recommendations were based only on results of trials in which patients were randomized 12 to 34 years ago, rarely reflected medical treatment improvements and often understated potential CAS hazards. Qualifying terminology summarizing recommendations or evidence lacked standardization, impeding guideline interpretation, and comparison. Conclusions-This systematic review has identified many opportunities to modernize and otherwise improve carotid stenosis management guidelines.

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U2 - 10.1161/STROKEAHA.115.003390

DO - 10.1161/STROKEAHA.115.003390

M3 - Article

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JO - Stroke

JF - Stroke

SN - 0039-2499

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Abbott A, Paraskevas KI, Kakkos SK, Golledge J, Eckstein H-H, Diaz-Sandoval LJ et al. Systematic review of guidelines for the management of asymptomatic and symptomatic carotid stenosis. Stroke. 2015;46(11):3288 - 3301. https://doi.org/10.1161/STROKEAHA.115.003390