ABC | Volume 111, Nº4, Octuber 2018

Review Article Oliveira et al Risk-benefit of carotid revascularization Arq Bras Cardiol. 2018; 111(4):618-625 Table 3 – Management of patients with Asymptomatic extracranial carotid stenosis 23-24 Carotid Stenosis Recommendations (Class and Evidence Level)* Periprocedural Risk to maintain clinical benefit < 60% OMT (IA) 60-69% OMT (IA); < 3% CEA + OMT (IIaB) ou CAS + OMT (IIbB) 70-99% OMT (IA) < 3% CEA + OMT (IIaB) ou CAS + OMT (IIbB) Occlusion OMT (IA) OMT: Optimized medical therapy; CEA: Carotid endarterectomy, CAS: Carotid angioplasty and stenting. (Classes of Recommendation: I - The benefit is greater than the risk and the treatment/procedure should be performed or administered; IIa - The benefit is greater than the risk, but further studies are needed, so that it reasonable to perform procedure or administer treatment; IIb - the benefit is equal to or greater than the risk and treatment/procedure may be considered. Levels of Evidence: A - Data derived from multiple randomized clinical trials or meta-analyses; B - Data derived from a single randomized clinical trial or multiple non‑randomized studies.) * For all patients: When procedure is indicated, CAS should only be performed if there is a high risk for CEA. Table 4 – Risk Subgroups for Carotid Intervention Subgroup Definition Symptomatic Occurrence of a stroke or a transient ischemic attack (TIA) within the previous six months, affecting the territory supplied by the affected carotid artery High-risk for Carotid Endarterectomy Congestive heart failure, ischemic cardiopathy, the need for associated cardiac surgery, severe pulmonary disease, contralateral carotid artery occlusion, paralysis of recurrent laryngeal nerve, carotid restenosis after procedure, cervical radiotherapy, prior cervical surgeries or age greater than 80 years In cases of severe asymptomatic carotid stenosis, the joint guideline of the American Heart Association and American Stroke Association for primary prevention of stroke, published in 2014, 30 and the guideline of the European Society of Cardiology, published in 2017, 31 recommend that the periprocedural risk should be less than 3% for a net benefit in the revascularization process. (Table 3) The risks associated with carotid intervention are heterogeneous, which makes it necessary to separate the patients into subgroups. (Table 4) The first important criterion in the definition of these subgroups is the presence or absence of symptoms, defined by the occurrence of a stroke or a transient ischemic attack (TIA) within the previous six months, affecting the territory supplied by the affected carotid artery. 1 The second criterion is based on the definition of high-risk patients for carotid endarterectomy: congestive heart failure, ischemic cardiopathy, the need for associated cardiac surgery, severe pulmonary disease, contralateral carotid artery occlusion, paralysis of recurrent laryngeal nerve, carotid restenosis after procedure, cervical radiotherapy, prior cervical surgeries or age greater than 80 years. 32 A systematic review published in 2015 examined the rates of stroke and death after CAS and CEA in twenty-one international records, which together represent more than 1,500,000 procedures performed between 2008 and 2015. 13 In asymptomatic patients not at high risk for endarterectomy, carotid stenting had a periprocedural risk lower than 3% in 43% of the cases, and a risk greater than 5% in 14% of the registries. For surgical revascularization in the same group, 95% of the registries reported risks lower than 3%. (Figure 1) In the group of symptomatic patients not at high risk, 72% of the registries after carotid angioplasty showed a greater than 6% incidence of stroke and death in 30 days. On the other hand, only 11% of the registries showed a risk above 6% among the patients submitted to endarterectomy. (Figure 2) Only three of the twenty-one registries analyzed reported data regarding patients with high risk for carotid endarterectomy. In one of them, the rate of events was greater than 3% in asymptomatic patients, for both CAS and CEA. In the group of symptomatic patients, all registries reported rates of stroke and death greater than 6% after CAS and two records showed rates above 6% after carotid endarterectomy. Carotid stenting: the age and operator effect The elderly population usually presents vessel tortuosity and a large burden of atherosclerosis, characteristics that increase complications after angioplasty procedures. Age has been associated with periprocedural stroke and death after CAS, this same finding was not reported after CEA. 33 A Cochrane meta‑analysis of 16 randomized clinical trials 34 and a subanalysis of the CREST trial 35 described an association of age ≥ 70 years and increased periprocedural risk after CAS. A meta-analysis of four randomized trials (EVA-3S, SPACE, ICSS and CREST) found that the periprocedural risk of stroke or death after CAS were 3% for patients younger than 60 years and 12% for those older than 70 years, whereas the periprocedural stroke and death risk remained stable at 5% across the entire age spectrum in the CEA group. 33 The possibility that the operator is a crucial factor for the good result of the carotid percutaneous intervention was 620