Variation in Carotid Artery Stenosis Measurements Among Facilities Seeking Carotid Stenting Facility Accreditation.

BACKGROUND: Based on the inclusion criteria of clinical trials, the degree of cervical carotid artery stenosis is often used as an indication for stent placement in the setting of extracranial carotid atherosclerotic disease. However, the rigor and consistency with which stenosis is measured outside of clinical trials are unclear. In an agreement study using a cross-sectional sample, we compared the percent stenosis as measured by real-world physician operators to that measured by independent expert reviewers. METHODS: As part of the carotid stenting facility accreditation review, images were obtained from 68 cases of patients who underwent carotid stent placement. Data collected included demographics, stroke severity measures, and the documented degree of stenosis, termed operator-reported stenosis (ORS), by 34 operators from 14 clinical sites. The ORS was compared with reviewer-measured stenosis (RMS) as assessed by 5 clinicians experienced in treating carotid artery disease. RESULTS: The median ORS was 90.0% (interquartile range, 80.0%-90.0%) versus a median RMS of 61.1% (interquartile range, 49.8%-73.6%), with a median difference of 21.8% (interquartile range, 13.7%-34.4%), P<0.001. The median difference in ORS and RMS for asymptomatic versus symptomatic patients was not statistically different (24.6% versus 19.6%; P=0.406). The median difference between ORS and RMS for facilities granted initial accreditation was smaller compared with facilities whose accreditation was delayed (17.9% versus 25.5%, P=0.035). The intraclass correlation between ORS and RMS was 0.16, indicating poor agreement. If RMS measurements were used, 72% of symptomatic patients and 10% of asymptomatic patients in the population examined would meet the Centers for Medicare and Medicaid Services criteria for stent placement. CONCLUSIONS: Real-world operators tend to overestimate carotid artery stenosis compared with external expert reviewers. Measurements from facilities granted initial accreditation were closer to expert measurements than those from facilities whose accreditation was delayed. Since decisions regarding carotid revascularization are often based on percent stenosis, such measuring discrepancies likely lead to increased procedural utilization.

Safety of carotid artery revascularization procedures in patients with atrial fibrillation.

BACKGROUND: Atrial fibrillation (Afib) is a major contributor to cerebrovascular events. Coexisting carotid artery disease is not uncommon in Afib patients, yet they have been excluded from major randomized clinical trials. Therefore, the aim of this study was to evaluate the safety of carotid endarterectomy (CEA) and carotid artery stenting (CAS) in Afib patients. METHODS: The Premier Healthcare Database was queried (2009-2015). Patients who underwent CEA or CAS were captured by International Classification of Diseases, Ninth Revision, Clinical Modification codes. Multivariable logistic modeling was implemented to examine the outcomes: in-hospital stroke, intracerebral hemorrhage (ICH), mortality, and stroke/death. RESULTS: There were 86,778 patients included. The majority were asymptomatic (n = 82,128 [94.6%]). Afib was reported in 6743 patients (7.8%). In terms of absolute outcomes in both asymptomatic and symptomatic patients, Afib patients (vs non-Afib patients) had higher mortality and stroke/death (asymptomatic: mortality, 0.4% vs 0.2%; stroke/death, 1.7% vs 1.2%; symptomatic: mortality, 6.9% vs 2.1%; stroke/death, 10.6% vs 4.5%; all P < .05). Adjusted analysis yielded higher odds of ICH (adjusted odds ratio [aOR], 1.29; 95% confidence interval [CI], 1.00-1.67), mortality (aOR, 1.59; 95% CI, 1.11-2.26), and stroke/death (aOR, 1.30; 95% CI, 1.08-1.58) in Afib patients. Although univariable analysis found Afib to be a statistically significant predictor of ischemic stroke, similar results could not be elucidated in the multivariable analysis (aOR, 1.17; 95% CI, 0.93-1.47). In Afib patients, important predictors of stroke/death included CAS (aOR, 1.80; 95% CI, 1.21-2.68) and symptomatic presentation (aOR, 5.00; 95% CI, 3.20-7.83). Other important predictors were type of preoperative medication use, age, and hospital size. CONCLUSIONS: Afib was associated with worse postoperative outcomes in patients with carotid artery disease. Symptomatic status in Afib patients is associated with a stroke/death risk that is higher than in recommended guidelines for CEA and particularly for CAS. Overall, CEA was associated with lower periprocedural ICH, mortality, and stroke/death in Afib patients compared with CAS.

Cavernous carotid artery aneurysms on a single institution: An epidemiological study with 201 patients.

OBJECTIVES: Cavernous carotid aneurysms (CCA) represent 2-9% of all intracranial aneurysms. For long considered benign lesions, these entities are unique when it comes to clinical presentation and management. Usually asymptomatic, CCAs can grow and rupture causing different manifestations. The lack of a long-term assessment of both treated and untreated CCAs' natural history justifies why there is no consensus regarding what are the recommended therapeutic measures. While some advocate that an intervention is always necessary, others consider that patients deserve an individualized evaluation. PATIENTS AND METHODS: We describe our single-institution experience in diagnosis, follow-up, and management of 201 CCAs. In addition, we evaluate the association of giant CCAs with aneurysms in other locations using a Chi-square test. RESULTS: 201 patients had 245 CCAs. 92% of the patients were women. The mean age at diagnosis was 61 years. Concomitant aneurysms were observed in 53.2% of the patients, and the middle cerebral artery was the most affected artery. 66 (30.6%) CCAs were considered "giant", and the follow-up period ranged from 1 to 23 years.The presence of a giant CCA seemed to hinder other aneurysms' formation - RR 0.47 (IC 95% 0.31-0.67), p < 0.0001. CONCLUSIONS: CCAs should be individually assessed. A conservative approach ought to be adopted for asymptomatic and oligosymptomatic lesions. Finally, a multidisciplinary team must evaluate the other situations, in order to define whether the microsurgical or the endovascular treatment is better option. Presence of a giant lesion within the cavernous sinus is associated with less occurrence of other aneurysms.

Approach to concurrent coronary and carotid artery disease: Epidemiology, screening and treatment / Abordagem da doença coronariana e carotídea concomitante: epidemiologia, rastreamento e tratamento

Summary The concomitance between coronary artery disease and carotid artery disease is known and well documented. However, it is a fact that, despite the screening methods for these conditions and the advances in surgical treatment, little has been achieved in terms of reducing the risk of complications in the perioperative period. Publications are scarce, being mostly composed of reports or case series. There is little agreement on the best initial therapeutic approach (myocardial versus carotid revascularization) or the best technique to be used (surgery with or without extracorporeal circulation, hybrid treatments, etc.). The authors performed a review of the evidence in this clinical scenario, raising pragmatic questions that help in the therapeutic decision.

Resumo A concomitância entre doença arterial coronária e doença carotídea é conhecida e já bem documentada. Fato é, porém, que, a despeito dos métodos de rastreio dessas condições e da evolução do tratamento cirúrgico, pouco se tem conseguido em termos de redução de risco de complicações no perioperatório. As publicações são escassas, sendo em sua maior parte compostas por relatos ou séries de caso. Há pouco consenso sobre qual a melhor abordagem terapêutica inicial (revascularização miocárdica versus carotídea), bem como sobre a melhor técnica a ser empregada (cirurgia com ou sem uso de circulação extracorpórea, tratamentos híbridos, etc.). Os autores realizaram uma revisão da evidência nesse cenário clínico, pontuando questões pragmáticas que ajudem na decisão terapêutica.

The association of Carotid Revascularization Endarterectomy versus Stent Trial (CREST) and Centers for Medicare and Medicaid Services Carotid Guideline Publication on utilization and outcomes of carotid stenting among "high-risk" patients.

OBJECTIVE: Since the 2004 approval by the United States Food and Drug Administration of carotid artery stenting (CAS), there have been two seminal publications about CAS reimbursement (Centers for Medicare and Medicaid Services guidelines; 2008) and clinical outcomes (Carotid Revascularization Endarterectomy versus Stent Trial [CREST]; 2010). We explored the association between these publications and national trends in CAS use among high-risk symptomatic patients. METHODS: The most recent congruent data sets of the Nationwide Inpatient Sample (NIS) were queried for patients undergoing carotid revascularization. The sample was limited to include only patients who were defined as "high-risk" if they had a Charlson Comorbidity Score of ≥3.0. Subgroup analyses were performed of high-risk patients with symptomatic carotid stenosis. Utilization proportions of CAS were calculated quarterly from 2005 to 2011 for NIS. Three time intervals related to Centers for Medicare and Medicaid Services guidelines and CREST publication were selected: 2005 to 2008, 2008 to 2010, and after 2010. Logistic regression with piecewise linear trend for time was used to estimate different trends in CAS use for the overall high-risk sample and for neurologically asymptomatic and symptomatic cases. Multivariate logistic regression was used to compare odds of postoperative mortality and stroke between these two procedures at different time intervals independent of confounding variables. RESULTS: During the study period, 20,079 carotid endarterectomies (CEAs) and 3447 CAS procedures were performed in high-risk patients in the NIS database. CAS utilization constituted 20.5% of carotid revascularization procedures among high-risk symptomatic patients, with a significant increase from 18.6% to 24.4% during the study period (P < .001). There was an initial increase during 2005 to 2008 in the rate of CAS compared with CEA, CAS utilization significantly decreased during 2008 to 2010 by a 3.3% decline in the odds ratio (OR) of CAS per quarter (OR, 0.967; 95% confidence interval [CI], 0.943-0.993; P = .002), and after CREST (after 2010), CAS utilization continued to increase significantly from the prepublication to the postpublication time interval. The odds of in-hospital mortality (OR, 2.56; 95% CI, 1.17-5.62; P = .019) and postoperative in-hospital stroke (OR, 1.53; 95% CI, 1.09-3.68; P = .024) were independently and significantly higher for CAS patients in the overall sample. CONCLUSIONS: The use of CAS for carotid revascularization in a high-risk cohort of patients has significantly increased from 2005 to 2011. Compared with CEA, CAS independently increased the odds of perioperative in-hospital stroke in all high-risk patients and of in-hospital mortality in symptomatic high-risk patients.

Approach to concurrent coronary and carotid artery disease: Epidemiology, screening and treatment.

The concomitance between coronary artery disease and carotid artery disease is known and well documented. However, it is a fact that, despite the screening methods for these conditions and the advances in surgical treatment, little has been achieved in terms of reducing the risk of complications in the perioperative period. Publications are scarce, being mostly composed of reports or case series. There is little agreement on the best initial therapeutic approach (myocardial versus carotid revascularization) or the best technique to be used (surgery with or without extracorporeal circulation, hybrid treatments, etc.). The authors performed a review of the evidence in this clinical scenario, raising pragmatic questions that help in the therapeutic decision.

Surgical repair of an extracranial carotid aneurysm / Tratamento cirúrgico de aneurisma da artéria carótida extracraniana

Aneurysms of the supra-aortic trunks are rare conditions that can cause peripheral neurological conditions or embolization resulting in stroke. The upper airways can even be affected and rupture is potentially fatal. We present a case of a patient with an aneurysm of the carotid bifurcation who was treated conventionally with reconstruction of the carotid bifurcation using a venous patch. Surgical treatment enabled accurate histopathological diagnosis and anatomic correction of the carotid bifurcation...

Os aneurismas de troncos supra-aórticos são condições raras, que podem ocasionar alterações neurológicas periféricas ou embolizações com consequentes acidentes vasculares encefálicos. Também podem ocasionar alterações em vias aéreas superiores e sua ruptura é potencialmente fatal. Relatamos o caso de um paciente portador de aneurisma de artéria carótida no nível da bifurcação carotídea, tratado de forma convencional, com reconstrução da bifurcação com remendo venoso. O tratamento convencional dos aneurismas de troncos supra-aórticos permite o adequado diagnóstico histopatológico e a correção anatômica da bifurcação carotídea...

Hybrid strategy for unstable patients with severe carotid and cardiac disease requiring surgery.

BACKGROUND: Concurrent severe carotid and cardiac disease is a challenging situation where staged surgery is probably the most common strategy. However, in patients with an unstable clinical presentation, the best approach is still a matter of debate. The aim of the study was to report in-hospital and midterm outcome in patients who received carotid artery stenting and synchronous cardiac surgery. METHODS: From June 1998 to July 2012, 54 consecutive patients who were treated at a high-volume university medical center with this hybrid approach were included in the study. All of the patients received carotid angioplasty while being administered aspirin and regular unfractionated heparin. Then, all of the patients were immediately transferred to the operating room for coronary and/or cardiac valve surgery. All of the patients were administered aspirin and clopidogrel once bleeding was ruled out, after surgery. RESULTS: There were 5 in-hospital surgical related deaths, and no patient suffered a stroke or required carotid urgent re-intervention. At follow-up (55 ± 28 months; range 1-144 months), there were no new neurological deficits, while one additional death occurred. CONCLUSIONS: In this series, synchronous carotid stenting and cardiac surgery were feasible with an acceptable complication rate in a high-surgical-risk population, which could not undergo staged procedures.

Electroconvulsive therapy performed 6 days after repair of an intracranial aneurysm using a liquid embolic system.

There exists a small, but growing body of literature that describes electroconvulsive therapy (ECT) performed on patients with intracranial aneurysms. These reports include patients with unrepaired aneurysms and others in which aneurysms have been repaired by clipping or coil embolization methods. To date, these cases have described favorable results and minimal complications. We describe the case of a 34-year-old woman, who received ECT 6 days after balloon-assisted embolization, with Onyx HD-500, of a 7-mm aneurysm of the ophthalmic segment of her left internal carotid artery. The patient experienced a significant reduction in depressive symptoms and tolerated a series of 8 treatments with no aneurysm-related complications. To our knowledge, this represents the earliest administration of ECT after repair of an intracranial aneurysm reported in the literature. Also, this is the only report in the literature of ECT performed after an intracranial aneurysm was repaired using the Onyx Liquid Embolic System.

Female sex does not influence 30-day stroke and mortality rates after carotid endarterectomy.

BACKGROUND: Sex-based differences in outcomes for the treatment of carotid arterial disease remains a controversial topic. The main objective of this study was to determine if gender differences influence 30-day stroke and mortality rates after carotid endarterectomy (CEA) in a large series of patients. METHODS: This is a retrospective study of all patients undergoing endarterectomy performed by a single surgeon between January 1, 1993 and December 15, 2010. The analysis included data from 1,046 CEAs (683 men and 363 women). RESULTS: There were no differences found in 30-day stroke, death, or combined stroke and death rates between women and men. The 30-day stroke rate was 1.6% for women and 1.8% for men (P = 0.98), with no significant differences between asymptomatic patients (1.7% for women vs. 1.2% for men; P = 0.70) or symptomatic patients (1.6% for women vs. 2.1% for men; P = 0.74). The 30-day mortality rate was 0.8% for women and 0.9% for men (P = 0.85) with no significant differences between asymptomatic patients (0.8% for women vs. 1.2% for men; P = 0.77) and symptomatic patients (0.8% for women vs. 0.7% for men; P = 0.84). There was a similar low risk for the combined outcome of stroke and death (1.9% for women vs. 2.2% for men; P = 0.92), with no differences between asymptomatic patients (1.7% for women vs. 1.6% for men; P = 0.89) or symptomatic patients (2.1% for women vs. 2.5% for men; P = 0.84). CONCLUSIONS: Female sex does not influence 30-day stroke and mortality rates after CEA, regardless of preoperative symptom status.

Incidence, predictors, and outcomes of hemodynamic instability following carotid angioplasty and stenting.

OBJECTIVE: To explore the incidence, predictors, and outcomes of hemodynamic instability (HI) following carotid angioplasty and stenting (CAS). METHODS: We retrospectively evaluated data on 257 CAS procedures performed in 245 patients from 2002 to 2011 at a single institution. The presence of periprocedural HI, as defined by hypertension (systolic blood pressure >160 mm Hg), hypotension (systolic blood pressure <90 mm Hg), and/or bradycardia (heart rate <60 beats per minute), was recorded. Clinically significant HI (CS-HI) was defined as periprocedural HI lasting greater than 1 hour in total duration. Logistic regression was used to analyze the role of multiple demographic, clinical, and procedural variables. RESULTS: Mean age was 70.9 ± 9.9 years (67% male). HI occurred following 84% (n = 216) of procedures. The incidence of hypertension, hypotension, and bradycardia was 54%, 31%, and 60%, respectively. Sixty-three percent of cases involved CS-HI. Recent stroke was an independent risk factor for the development of CS-HI (odds ratio, 5.24; confidence interval, 1.28-21.51; P = .02), whereas baseline chronic obstructive pulmonary disease was protective against CS-HI (odds ratio, 0.34; confidence interval, 0.15-0.80; P = .01). Patients with CS-HI were more likely to experience periprocedural stroke compared to other patients (8% vs 1%; P = .03). There were no significant differences in the incidence of mortality or other major complications between those with and without CS-HI. CONCLUSIONS: HI represents a common occurrence following CAS. While the presence of periprocedural HI alone did not portend a worse clinical outcome, CS-HI was associated with increased risk of stroke. Expeditious intervention to prevent and manage CS-HI is of critical importance in order to minimize adverse clinical events following CAS.

A FDG-18F na distinþÒo de placa aterosclerótica: inovaþÒo em tecnologia PET/CT / FDG-18F in differentiating atherosclerotic plaque: innovation in PET/CT technology

A composiþÒo da placa aterosclerótica, em contrapartida ao grau de estenose arterial, parece ser o determinante crítico da vulnerabilidade e trombogenicidade da placa. O fluordesoxiglucose (FDG-18F), pode ser usado para obter imagensda atividade celular inflamatória de forma nÒo invasiva através da tecnología PET. O objetivo principal do presente estudo foi averiguar a viabilidade da tecnologia FDG-18F PET na avaliaþÒo do processo inflamatório instalado nas placas ateroscleróticas, e, dessa forma, promover a distinþÒo de placas ateroscleróticas através da relaþÒo entre acúmulo do radiofármaco e as características funcionais da lesÒo aterosclerótica. Estudo epidemiológico prospectivo, duplo cego randomizado, transversal foi realizado em cinco pacientes, seis controles e, os mesmos, foram submetidos ao exame diagnóstico FDG-18F PET/CT. Os valores de suv em artérias carótidas e veias jugulares do próprio paciente e o comparativo com o grupo controle foram correlacionados através de uma avaliaþÒo qualitativa do coeficiente de correlaþÒo de pearson. Através de um estudo descritivo comparativo inter-grupos na carótida direita observa-se que 64.9% da média dos valores de SUV corresponde aos pacientes em estudo. Na análise efetuada intra-grupo da carótida direita com a jugular direita dos pacientes em estudo, observou-se um valor médio de SUV 26.2% superior na artéria carótida. No grupo controle, a diferenþa entre os níveis médios de captaþÒo do FDG-18F foi inferior a 10%. Através da endarterectomia, foi possível realizar um estudo anátomo patológico e, dessa forma, identificar a presenþa de conteúdo inflamatórionas carótidas avaliadas, caracterizando assim placas instáveis. A tecnologia FDG-18F PET mostrou-se exequível favorecendo uma boa correlaþÒo histopatológica entre o processo inflamatório instalado nas placas ateroscleróticas e os níveis mensurados de SUV. (AU)

An ethological approach to the study of behavioral disorders provides key information on functionalaspects of behavior that characterize certain pathologies. The purpose of this study was to describe non-verbal behavioral units presented by a group of 14 women with social phobia (SP) and a control groupof 13 women during a clinical interview and to evaluate the possible differences between these twogroups. The 19 behavior units were selected with the index of concordance between the observers tauKendall = 0.795 (p = 0.000). People with SP supported the way they spoke with their hands and placedtheir hands on their legs, in comparison with the control group. People with SP nodded more often,touched their faces, pressed their lips, licked their lips and touched their hair more frequently than thecontrol group. The article suggests that a systematic evaluation of non-verbal behavior may be impor-tant in conducting a full evaluation of patients with SF in a clinical environment, and may contribute toevaluating the efficiency of the treatment.(AU)

A FDG-18F na distinção de placa aterosclerótica: inovação em tecnologia PET/CT / FDG-18F in differentiating atherosclerotic plaque: innovation in PET/CT technology

A composição da placa aterosclerótica, em contrapartida ao grau de estenose arterial, parece ser o determinante crítico da vulnerabilidade e trombogenicidade da placa. O fluordesoxiglucose (FDG-18F), pode ser usado para obter imagensda atividade celular inflamatória de forma não invasiva através da tecnología PET. O objetivo principal do presente estudo foi averiguar a viabilidade da tecnologia FDG-18F PET na avaliação do processo inflamatório instalado nas placas ateroscleróticas, e, dessa forma, promover a distinção de placas ateroscleróticas através da relação entre acúmulo do radiofármaco e as características funcionais da lesão aterosclerótica. Estudo epidemiológico prospectivo, duplo cego randomizado, transversal foi realizado em cinco pacientes, seis controles e, os mesmos, foram submetidos ao exame diagnóstico FDG-18F PET/CT. Os valores de suv em artérias carótidas e veias jugulares do próprio paciente e o comparativo com o grupo controle foram correlacionados através de uma avaliação qualitativa do coeficiente de correlação de pearson. Através de um estudo descritivo comparativo inter-grupos na carótida direita observa-se que 64.9% da média dos valores de SUV corresponde aos pacientes em estudo. Na análise efetuada intra-grupo da carótida direita com a jugular direita dos pacientes em estudo, observou-se um valor médio de SUV 26.2% superior na artéria carótida. No grupo controle, a diferença entre os níveis médios de captação do FDG-18F foi inferior a 10%. Através da endarterectomia, foi possível realizar um estudo anátomo patológico e, dessa forma, identificar a presença de conteúdo inflamatórionas carótidas avaliadas, caracterizando assim placas instáveis. A tecnologia FDG-18F PET mostrou-se exequível favorecendo uma boa correlação histopatológica entre o processo inflamatório instalado nas placas ateroscleróticas e os níveis mensurados de SUV.

An ethological approach to the study of behavioral disorders provides key information on functionalaspects of behavior that characterize certain pathologies. The purpose of this study was to describe non-verbal behavioral units presented by a group of 14 women with social phobia (SP) and a control groupof 13 women during a clinical interview and to evaluate the possible differences between these twogroups. The 19 behavior units were selected with the index of concordance between the observers tauKendall = 0.795 (p = 0.000). People with SP supported the way they spoke with their hands and placedtheir hands on their legs, in comparison with the control group. People with SP nodded more often,touched their faces, pressed their lips, licked their lips and touched their hair more frequently than thecontrol group. The article suggests that a systematic evaluation of non-verbal behavior may be impor-tant in conducting a full evaluation of patients with SF in a clinical environment, and may contribute toevaluating the efficiency of the treatment.

[Diagnosis and treatment of asymptomatic extracranial atherosclerotic carotid artery disease]. / Diagnóstico y tratamiento de la enfermedad carotídea aterosclerótica extracraneal asintomática.

The reported prevalence of asymptomatic atherosclerotic disease of the extracranial internal carotid artery is up to 12.5%. Carotid angioplasty has not yet proven safe and effective enough to prevent ischemic stroke in these patients. Randomized studies showed that carotid endarterectomy is superior to medical therapy in reducing the risk of ischemic stroke when performed by surgical teams with complication rates (stroke or death) of less than 3%. However, recruitment of these patients began more than 25 years ago, when the use of antiplatelet agents was lower than today, the treatment of hypertension was less effective than currently, and statins were not considered as key components of vascular prevention strategies. Optimizing the quality of medical treatment in recent decades has led to a significant reduction in stroke risk in patients not undergoing surgery. Based on these observations and with the exception of specific cases, medical therapy is the treatment of choice for patients with asymptomatic atherosclerotic disease of the extracranial carotid arteries.

Diagnóstico y tratamiento de la enfermedad carotídea aterosclerótica extracraneal asintomática / Diagnosis and treatment of asymptomatic extracranial atherosclerotic carotid artery disease

La enfermedad aterosclerótica asintomática de la arteria carótida interna extracraneal alcanza una prevalencia de hasta el 12.5%. La angioplastia carotídea todavía no ha demostrado ser lo suficientemente segura y eficaz para prevenir el ACV isquémico en estos pacientes. Estudios aleatorizados demostraron que la endarterectomía carotídea es superior al tratamiento médico en cuanto a reducción del riesgo de ACV isquémico si es realizada por equipos con tasas de complicaciones (ACV o muerte) menores que 3%. Sin embargo, los pacientes evaluados en estos estudios comenzaron a reclutarse hace más de 25 años, cuando la utilización de antiagregantes plaquetarios era menor que la actual, el tratamiento de la hipertensión arterial era menos efectivo y todavía no se usaban estatinas como componentes fundamentales de los esquemas de prevención vascular. La optimización de la calidad del tratamiento médico en las últimas décadas ha llevado a una significativa reducción del riesgo de ACV en pacientes no intervenidos quirúrgicamente. En base a estas observaciones y con la excepción de casos específicos, el tratamiento médico es la opción terapéutica de elección en pacientes con enfermedad aterosclerótica carotídea extracraneal asintomática.

The reported prevalence of asymptomatic atherosclerotic disease of the extracranial internal carotid artery is up to 12.5%. Carotid angioplasty has not yet proven safe and effective enough to prevent ischemic stroke in these patients. Randomized studies showed that carotid endarterectomy is superior to medical therapy in reducing the risk of ischemic stroke when performed by surgical teams with complication rates (stroke or death) of less than 3%. However, recruitment of these patients began more than 25 years ago, when the use of antiplatelet agents was lower than today, the treatment of hypertension was less effective than currently, and statins were not considered as key components of vascular prevention strategies. Optimizing the quality of medical treatment in recent decades has led to a significant reduction in stroke risk in patients not undergoing surgery. Based on these observations and with the exception of specific cases, medical therapy is the treatment of choice for patients with asymptomatic atherosclerotic disease of the extracranial carotid arteries.