ABC | Volume 111, Nº4, Octuber 2018

Review Article Oliveira et al Risk-benefit of carotid revascularization Arq Bras Cardiol. 2018; 111(4):618-625 outcomes after carotid stenting between 2008 and 2015, suggesting that this modality of intervention, although less invasive, has higher rates of complications even in patients with high surgical risk. 13 The data concerning the effect of operator in CAS show that prior experience is important and can influence the rate of serious complications. A difference of almost 100% in the incidence of 30-day stroke and death outcomes between different groups of operators has already been observed in clinical trials. 40 The annual volume of carotid procedures performed by the operator is the factor that best correlated with lower rates of complications. 40 The indication for carotid intervention in symptomatic patients showed a greater benefit in the first weeks of the event. In this context, the joint guideline of the American Heart Association and American Stroke Association for prevention of stroke in symptomatic patients, published in 2014, recommends as class IIa that carotid revascularization occurs within two weeks of the index event, if there are no complications that contraindicate the procedure. 30 The 2017 guideline of the European Society of Cardiology ( ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial diseases, in collaboration with the European Society for Vascular Surgery ), maintained this recommendation. 31 The indication for carotid intervention is still questionable in the case of asymptomatic patients, since the studies published up to now have shown a high rate of unnecessary procedures. 53 Currently, some studies try to identify asymptomatic patients with higher risk who could undergo a more cost-effective carotid revascularization procedure. Conclusion Severe lesion of the extracranial carotid artery is responsible for 14% of all cerebral vascular accidents. Carotid revascularization has been performed for over 50 years, and several studies have proven that the intervention is capable of preventing this outcome, but with a not inconsiderable risk of serious complications. More recently, carotid angioplasty procedures have broadened the range of invasive options, but the expected reduction in periprocedural risk was not observed. Additionally, the increased incidence of atherosclerosis resulted in a great heterogeneity of patients who are possible candidates for endarterectomy or stenting , and the evolution of pharmacological therapy changed the risk‑benefit ratio of intervention in many cases of atherosclerotic disease. Concerning patients treated with the current best medical therapy, carotid intervention should only be performed when it is documented a periprocedural risk of less than 6% in symptomatic patients. Although major guidelines endorse intervention in asymptomatic patients provided that the periprocedural risk is less than 3%, the narrow magnitude of the absolute stroke prevention places carotid intervention as a questionable procedure in an unselected asymptomatic population. Author contributions Conception and design of the research: Oliveira PP, Vieira JLC, Portal VL; Acquisition of data: Oliveira PP, Guimarães RB; Analysis and interpretation of the data: Oliveira PP, Portal VL; Writing of the manuscript: Oliveira PP, Vieira JLC, Guimarães RB, Almeida ED, Savaris SL, Portal VL; Critical revision of the manuscript for intellectual content: Oliveira PP, Vieira JLC, Almeida ED, Savaris SL, Portal VL. Potential Conflict of Interest No potential conflict of interest relevant to this article was reported. Sources of Funding There were no external funding sources for this study. Study Association This study is not associatedwith any thesis or dissertationwork. 1. 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