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Abstract
Objective: Specific guidelines for management of cerebrovascular risk in women are currently lacking. This study aims to provide a consensus expert opinion to help make clinical decisions in women with carotid stenosis.
Methods: Proposals for the use of carotid endarterectomy (CEA), carotid stenting (CAS), and medical therapy for stroke prevention in women with carotid stenosis were provided by a group of 9 international experts with consensus method.
Results: Symptomatic women with severe carotid stenosis can be managed by CEA provided that the perioperative risk of the operators is low (<4%). Periprocedural stroke risks may be increased in symptomatic women if revascularization is performed by CAS; however, the choice of CAS vs CEA can be tailored in subgroups best fit for each procedure (e.g., women with restenosis or severe coronary disease, best suited for CAS; women with tortuous vessels or old age, best suited for CEA). There is currently limited evidence to consider medical therapy alone as the best choice for women with neurologically severe asymptomatic carotid stenosis, who should be best managed within randomized trials including a medical arm. Medical management and cardiovascular risk factor control must be implemented in all women with carotid stenosis in periprocedural period and lifelong regardless of whether or not intervention is planned.
Conclusions: The suggestions provided in this article may constitute a decision-making basis for planning treatment of carotid stenosis in women. Most recommendations are of limited strength; however, it is unlikely that new robust data will emerge soon to induce relevant changes.
GLOSSARY
- ACAS=
- Asymptomatic Carotid Atherosclerosis Study;
- ACST1=
- Asymptomatic Carotid Surgery 1 Trial;
- ARR=
- absolute risk reduction;
- CAS=
- carotid stenting;
- CEA=
- carotid endarterectomy;
- CHD=
- coronary heart disease;
- CI=
- confidence interval;
- CREST=
- Carotid Revascularization Endarterectomy vs Stenting Trial;
- CSTC=
- Carotid Stenting Trialists' Collaboration;
- DM=
- diabetes mellitus;
- ECST=
- European Carotid Surgery Trial;
- EVA-3S=
- Endarterectomy vs Angioplasty in Patients With Severe Symptomatic Carotid Stenosis;
- GRADE=
- Grades of Recommendation Assessment, Development and Evaluation;
- HR=
- hazard ratio;
- ICSS=
- International Carotid Stenting Study;
- MI=
- myocardial infarction;
- NASCET=
- North American Symptomatic Carotid Endarterectomy;
- OR=
- odds ratio;
- RCT=
- randomized controlled trial;
- RRR=
- relative risk reduction;
- SAPPHIRE=
- Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy;
- SPACE=
- Stent-Protected Angioplasty vs Carotid Endarterectomy
Footnotes
Go to Neurology.org for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.
Supplemental data at www.neurology.org
- Received October 24, 2012.
- Accepted in final form March 11, 2013.
- © 2013 American Academy of Neurology
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