American Academy of Neurology

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Released February 21, 2013

Don’t recommend CEA for asymptomatic carotid stenosis unless the complication rate is low (<3%).

Based on studies reporting an upfront surgical complication rate ranging from 2.3% (ACAS) to 3.1% (ACST) among patients undergoing carotid endarterectomy (CEA) for asymptomatic stenosis of >60%, and an absolute risk reduction for stroke or death of roughly 5-6% in the surgical group at 5 years, several specialty societies (Goldstein et al, 2011; Brott et al, 2011; Chaturvedi et al; Ricotta et al) have recommended that surgery for asymptomatic patients should be reserved for those with a perioperative complication risk of <3% and a life expectancy of greater than 3–5 years. The cited 3% threshold for complication rates may be high because more recent studies have reported lower stroke rates with improvements in both surgical (Brott, 2010) and medical (Marquardt) management. However, there are no recent randomized trials comparing these treatments. Given this, the more recent AHA guidelines (Brott 2011) state that it is “reasonable” to perform CEA for asymptomatic patients with >70% stenosis if the surgical complication rate is “low.”

Reported complication rates vary widely by location (Kresowik), and are dependent on how complications are tracked (self-report vs. neurologist’s evaluation vs. administrative data (Wolff T). Despite calls for rigorous monitoring 15 years ago (Goldstein), most patients will likely need to rely on the surgeon’s self-reported rates.

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

How The List Was Created

The American Academy of Neurology (AAN) established aChoosing Wisely® Working Group to develop its list of recommendations. Members of this group were selected to broadly represent varying practice settings and neurological subspecialties. Neurologists with methodological expertise in evidence-based medicine and practice guideline development were also included. The working group solicited recommendations from AAN members, which were then rated based upon their judgments of harm and benefit that would result based upon compliance with the recommendation. Based on committee voting and a literature review, candidate recommendations were sent to relevant AAN sections, committees, specialty societies and patient advocacy groups for review and comment. The working group reviewed this feedback and voted on the final Top Five recommendations, which were approved by the AAN Practice Committee and Board of Directors.

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Walker MD, Marler JR, Goldstein M, Grady PA, Toole JF, Baker WH, Castaldo JE, Chambless LE, Moore WS, Robertson JT, Young B, Howard VJ, Marler JR, Purvis S, Vernon DD, Needham K, Beck P, Celani VJ, Sauerbeck L, von Rajcs JA, Atkins D. Endarterectomy for asymptomatic carotid artery stenosis. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study (ACAS). JAMA. 1995 May 10;273(18):1421-8.

MRC Asymptomatic Carotid Surgery Trial (ACST) Collaborative Group. Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomized controlled trial. Lancet [Internet]. 2004 [cited 2013 Jan 3];363(9420):1491-1502.

Goldstein LB, Bushnell CD, Adams RJ, Appel LJ, Braun LT, Chaturvedi S, Creager MA, Culebras A, Eckel RH, Hart RG, Hinchey JA, Howard VJ, Jauch EC, Levine SR, Meschia JF, Moore WS, Nixon JV, Pearson TA. Guidelines for the primary prevention of stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke [Internet]. 2011 Feb [cited 2013 Jan 3];42(2):517-84.

Chaturvedi S, Bruno A, Feasby T, Holloway R, Benavente O, Cohen SN, Cote R, Hess D, Saver J, Spence JD, Stern B, Wilterdink J. Carotid endarterectomy: an evidence-based report of the Technology and Therapeutics Committee of the American Academy of Neurology. Neurology [Internet]. 2005 [cited 2013 Jan 3];65:794-801.

Ricotta JJ, Aburahma A, Ascher E, Eskandari M, Faries P, Lal BK. Updated Society for Vascular Surgery guidelines for management of extracranial carotid disease. J Vasc Surg [Internet]. 2011 Sep [cited 2013 Jan 3];54(3)e1-31.

Kresowik TF, Bratzler DW, Kresowik RA, Hendel ME, Grund SL, Brown KR, Niladena DS. Multistate improvement in process and outcomes of carotid endarterectomy. J Vasc Surg [Internet]. 2004 [cited 2013 Jan 3];39:372-380.

Brott TG, Hobson RW II, Howard G, Roubin GS, Clark WM, Brooks W, Mackey A, Hill MD, Leimgruber PP, Sheffet AJ, Howard VJ, Moore WS, Voeks JH, Hopkins LN, Cutlip DE, Cohen DJ, Popma JJ, Ferguson RD, Cohen SN, Blackshear JL, Silver FL, Mohr JP, Lal BK, Meschia JF. Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med [Internet]. 2010 Jul 1 [cited 2013 Jan 3];363(1):11-23.

Marquardt L, Geraghty OC, Mehta Z, Rothwell PM. Low risk of ipsilateral stroke in patients with asymptomatic carotid stenosis on best medical treatment: a prospective, population-based study. Stroke [Internet]. 2010 [cited 2013 Jan 1];41:e11-e7.

Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL, Cates CU, Creager MA, Fowler SB, Friday G, Hertzberg VS, McIff EB, Moore WS, Panagos PD, Riles TS, Rosenwasser RH, Taylor RJ. 2011 ASA/ACCF/AHA/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease. Circulation [Internet]. 2011 [cited 2013 Jan 3];124:e54-e130.

Wolff T,Guirguis-Blake J, Miller T, Gillespie M, Harris R. Screening For Asymptomatic Carotid Artery Stenosis. Rockville: Agency for Health Care Quality (US). 2007 Dec. Appendix 4-Evidence Table on Complication Rates for Carotid Endarterectomy.

Goldstein LB, Moore WS, Robertson JT, Chaturvedi S. Complication rates for carotid endarterectomy—a call to action. Stroke [Internet]. 1997[cited 2013 Jan 3];28(5):889-890.