Endarterectomy protocol

[Apoplexy__]

From Step Up To Medicine:
-Symptomatic patients, >70% carotid stenosis --> carotid endarterectomy
-Symptomatic patients, <70% carotid stenosis --> Control risk factors + ASA
-Asymptomatic patients --> Control risk factors + ASA

But UWorld (QID = 3529) stratifies asymptomatic patients into >60% and <60%, saying >60% --> endarterectomy. It looks like they're going off a clinical trial that SUTM mentions, which found minor benefit in the >60% stenosis cohort. This trial was 1 of 4, where the other 3 found no benefit of endarterectomy in asymptomatic patients.

But it doesn't make sense for your threshold of stenosis in asymptomatic patients to be lower...who should I go with?

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[thehundredthone]

Both ACAS and ACST found that there was a absolute risk reduction of ~5% and >50% relative risk reduction in asymptomatic patients with >60% stenosis. ACAS was actually stopped because of the significant benefit. AHA supports this recommendation, caveat being that the perioperative mortality and stroke rate should be around 3%. It's still controversial though.

The sense is in the fact that the symptomatic people who have already had a TIA or a stroke did not receive a much greater immediate overall benefit from endarterectomy for stenosis <70% but there was some in the long run. Plenty of surgeons do recommend it for symptomatic stenosis >50%. From http://stroke.ahajournals.org/content/38/2/707.full

A reanalysis of pooled individual data from all three symptomatic CEA trials, that included the much smaller VA Symptomatic Carotid Surgery Trial, yielded 6092 patients. The new analysis concluded that CEA has the following effects

1. It increased the 5-year risk of ipsilateral ischemic stroke in patients with <30% stenosis.
2. It lacked any effect in patients with 30% to 49% stenosis.
3. It produced marginal benefit in those with 50% to 69% stenosis at 3 years, but the benefit increased over 5 and 8 years.
4. It is highly beneficial in those with 70% stenosis or greater without near-occlusion.
5. It decreased disabling stroke only when the carotid stenosis was 80% or greater.
6. The overall perioperative risk of stroke or death is 7.1%.[/URL]

EDIT: Also see http://forums.studentdoctor.net/threads/carotid-endarterectomy-in-the-prevention-of-stroke.297144/

 

[Apoplexy__]

Beautiful answer, thank you. Looks like I'll be remembering symptomatic >70% and asymptomatic >60% then.

I should have found that old thread there, whoops.

 

[as90]

I had written down on my DIT book:
surgical indications for endarterectomy

-symptomatic pts c narrowing of 70-99%
-symptomatic MEN c narrowing of 50-69%
-asymptomatic pts c narrowing of 80-89% provided life expectancy is >5 years and surgeon has a perioperative complication of <3%

 

[notbobtrustme]

I've gotten pimped on this like 6 times between 4 different doctors and they all give me varied answers.

The head of vascular surgery says ">80% stenosis and asymptomatic, clean it out, if ever symptomatic, clean it out."

Another surgeon says ">70% and asymptomatic and >50% and symptomatic"

SUTS (2014) says >80% and asymptomatic, clean it out. Symptomatic, clean it out.

Uworld says >60% and symptomatic, clean it out, >70%, clean it out.

wtf.

 

[surgok]

These are from up to date.

for men:
symptomatic and >50% = CEA
asymptomatic and >60% = CEA

for women:
>70% regardless of symptoms

 

[Fatalis]

These are from up to date.

for men:
symptomatic and >50% = CEA
asymptomatic and >60% = CEA

for women:
>70% regardless of symptoms

I think uworld just updated the question too because that is what they say as well.