Systematic Review of the Discrepancies Between Guideline Recommendations on Carotid Revascularization in Patients with Symptomatic Carotid Artery Disease

BACKGROUND The optimal treatment of carotid artery disease in patients who have suffered a recent stroke or transient ischemic attack has potentially changed since best medical therapy has improved, and the perioperative risk of carotid revascularization has decreased. The objective is to highlight consensus and discrepancies between guidelines on carotid revascularization in patients with symptomatic carotid artery disease.METHODS We systematically searched PubMed for international guidelines from around the world published after January 1, 2015 on carotid revascularization in patients with symptomatic carotid artery disease. All recommendations and strengths of recommendations on carotid endarterectomy and carotid artery stenting for patients with mild (<50%), moderate (50%-69%), and severe (>70%) stenosis were collected and analyzed.RESULTS Sixteen guidelines on carotid revascularization from 14 different regions were identified. Two guidelines suggested carotid revascularization for patients with mild stenosis, when refractory to optimal medical therapy. All guidelines recommended carotid revascularization, with varying certainty, for at least a subgroup of patients with moderate carotid stenosis. All guidelines strongly recommend carotid revascularization for patients with severe stenosis. Plaque vulnerability was suggested to be an indication for carotid revascularization by 2 guidelines (13%).CONCLUSION There are important discrepancies between current guidelines for patients with mild and moderate stenosis. Contemporary clinical trials are essential to evaluate the comparative effectiveness of current optimal medical therapy and revascularization and assess the influence of plaque vulnerability on the effectiveness of treatments. The development, validation, and impact evaluation of a novel risk score could enhance the integration of plaque vulnerability assessments into clinical decision-making.