The development of medical consultation norms or guidelines is an important measure to improve the effectiveness of consultation and treatment, to ensure the best prognosis for patients, and to rationalize economic medical expenditures and costs. This guideline is about extracranial carotid and vertebral artery lesions (ECVD), which was revised and upgraded by the ACCF/AHA guideline writing committee based on previous versions and summarizing relevant literature since May 2010. This article provides some excerpts from it for your reference and valuable comments, as well as a reference base for clinical practice.
Extracranial vascular lesions and stroke.
The extracranial vasculature emphasizes the network of vessels that affect the blood supply to brain tissue and includes primarily the carotid system and the vertebrobasilar system. Extracranial vascular lesions are the main cause of ischemic stroke. The types of clinicopathology include: atherosclerosis, myofibrillar dysplasia, cystic necrosis of the middle layer of the artery, arteritis, and entrapment. Of these, atherosclerosis is the leading cause, and since atherosclerosis is a systemic disease, patients with extracranial vascular lesions are also at risk for other vascular events, such as ischemic heart disease and peripheral vascular disease. Ischemic stroke is the 3rd leading disease causing death after cardiovascular disease and cancer, and is the leading cause of disability. Epidemiological analysis shows that 7-18% of first ischemic strokes are due to >60% stenosis of the carotid and basilar arteries. The following are guidelines for the diagnosis and treatment of this disease, primarily atherosclerotic lesions.
Screening and evaluation of asymptomatic carotid artery stenosis.
1. In asymptomatic patients with known or suspected carotid stenosis, Doppler ultrasound is recommended as the preferred measure to evaluate the degree of stenosis and its hemodynamic impact. (I/C)
2. In asymptomatic patients with a carotid murmur, Doppler ultrasound is recommended to screen for the degree of stenosis. (IIa/C)
3. For follow-up patients with >50% stenosis, annual application of Doppler ultrasound is recommended for assessment of lesion changes; it is also recommended as a means of assessing response to therapy, and if follow-up shows stable lesions, the follow-up time frame may be extended appropriately. (IIa/C)
4. For patients with peripheral vascular disease, coronary artery disease, and atherosclerotic aneurysms without symptoms of cerebral ischemia, the application of Doppler ultrasound should be considered for screening of carotid artery stenosis. (IIb/C)
5. Doppler ultrasound screening for carotid artery lesions may be considered in people with no symptoms and no signs of atherosclerosis, but with 2 or more risk factors (hypertension, hyperlipidemia, smoking, history of vascular events before age 60 in 1st-degree relatives, history of ischemic stroke); however, and there is no current evidence of prognostic impact. (IIb/C)
6. The routine use of Doppler ultrasound for screening of carotid lesions is not recommended in people with no symptoms, no risk factors for atherosclerosis, and in patients with neurological injury due to non-ischemic factors, such as tumors (III/C)
Diagnosis of symptomatic extracranial vascular lesions.
1. For patients with temporary retinal or neurohemispheric symptoms suspected to be caused by ischemia, screening for ECVD by noninvasive imaging is recommended. (I/C)
2. Doppler ultrasound is recommended as a measure for the detection of symptomatic carotid stenosis. (I/C)
3.If Doppler ultrasound is not suggestive, MRA and CTA are recommended as screening options for symptomatic carotid stenosis. (I/C)
4.If there is no clear sign of intracranial or extracranial vascular lesion to explain neurological symptoms, echocardiography is recommended to detect the presence of possible cardiogenic emboli. (I/C)
5. When extracranial vascular lesions are detected, assessment of intracranial vascular lesions by CTA, MRA or selective cerebral angiography is recommended. (IIa/C)
6.For patients who may require revascularization, MRA, CTA, and angiography are recommended. (IIa/C)
7.When noninvasive imaging shows unclear or contradictory findings, angiography is recommended to clarify intracranial/extracranial vascular lesions. (IIa/C)
8, In patients with severe vascular calcification and renal insufficiency, non-contrast MRA is recommended. (IIa/C)
9, If non-specific neurological symptoms that may be caused by cerebral ischemia cannot be excluded is, Doppler ultrasound screening can be done (IIb/C)
10.If Doppler ultrasound, MRA, CTA suggest total occlusion of carotid artery, further action pulsography can be done to understand the lumen to determine whether revascularization can be performed (IIb/C)
11.For patients who need to limit the use of contrast agent due to renal insufficiency, the application of angiography may be considered to evaluate a single vascular lesion (IIb/C)
Pharmacological treatment of extracranial vascular lesions
The main aim of pharmacological treatment is to control the various risk factors leading to stroke.
1. For patients with asymptomatic ECVD, blood pressure control below 140/90 mmg is recommended (I/A); for patients with symptomatic ECVD, blood pressure control (below 140/90 mmg) is recommended except in the hyperacute phase (IIa/C)
2. Recommend smoking cessation to slow down the process of atherosclerosis to reduce the incidence of stroke (I/A)
3.Recommend the application of statin drugs to control hyperlipidemia, LDL 100mg/dL or less (I/B); LDL to 70mg/dL or less in high-risk patients (IIa/B); for patients who cannot tolerate lipid-lowering therapy, bile acid chelators or niacin can be used as alternative (IIa/B)
4. In ECVD patients with combined diabetes, it is recommended to apply diet control, exercise, and glucose-lowering therapy to control blood glucose (IIa/A); meanwhile, tadalafil is applied to control LDL below 70mg/dL (IIa/B)
Another focus of pharmacological treatment is antithrombotic therapy.
1, recommend the application of aspirin alone (75-325mg/d), clopidogrel (75mg/d) or combined aspirin and pansentin, but not aspirin combined with clopidogrel for antithrombotic prophylaxis and treatment (I/B)
2. For ECVD patients with anticoagulation indication such as combined atrial fibrillation and mechanical flap, it is recommended to apply vitamin K antagonist with INR control around 2.5 (IIa/C)
3. For patients with stroke or TIA, clopidogrel combined with aspirin therapy is not recommended for 3 months (III/B); heparin or low-molecular heparin anticoagulation is not recommended in patients with acute ischemic stroke and TIA (III/B)
Carotid revascularization.
1. Carotid endarterectomy (CEA) is recommended in patients with symptomatic carotid stenosis with non-invasive imaging means suggesting >70% stenosis (I/A) or angiography suggesting >50% stenosis (I/B), and estimated perioperative stroke or mortality is less than 6%
2. Carotid artery stenting (CAS) is recommended as a candidate measure for CEA (I/B)
3. CEA is recommended in asymptomatic patients with carotid stenosis greater than 70% and with low perioperative stroke and mortality (IIa/A)
4. In elderly patients, especially if the vascular conditions are not suitable for interventional treatment, CEA (IIa/B) is recommended as the first choice
5. In patients with neck conditions unsuitable for surgery, CAS (IIa/B) is recommended as the first choice
6.For TIA or stroke within 2 weeks, early revascularization (IIa/B) is recommended in the absence of contraindications
7. For asymptomatic patients with angiographic indication of carotid stenosis of 60% and ultrasound indication of 70%, prophylactic CAS (IIb/B) may be considered
8.For carotid stenosis less than 50%, sexual revascularization (III/A) is not recommended
9.For chronic total occlusive lesions, revascularization for occlusive lesions is not recommended (III/C)
10.For patients with severe cerebral dysfunction, revascularization is not recommended (III/C)
Perioperative management of carotid endarterectomy.
1.Recommended application of aspirin (81-325mg/d) (I/A)
2.Recommended postoperative continuous application of aspirin (75-325mg/d), clopidogrel (75mg/d) or low-dose aspirin combined with pentoxifylline (I/B)
3.Recommended good perioperative blood pressure control (I/C)
4.Recommended to record neurological examination results in the preoperative and 24h postoperative period (I/C)
5.It is recommended to apply carotid patch when CEA closes the incision (IIa/B)
6. It is recommended to apply statin after carotid endarterectomy (IIa/B)
7. Non-invasive imaging follow-up is recommended at 1 month, 6 months, and annually after carotid endarterectomy, including contralateral vascularity, until the patient does not require further vascular intervention (IIa/C)
Perioperative management of carotid artery stenting.
1. Recommend preoperative CAS, for at least 30 days, aspirin (81-325 mg/d) + clopidogrel (75 mg/ of) dual anti-treatment, and if clopidogrel is not tolerated, co-application of ticlopidine (250 mg BID) (I/C)
2.Recommended perioperative anti-hypertensive therapy for CAS (I/C)
3. Recommend recording neurological findings preoperatively and within 24 h postoperatively (I/C)
4.Recommended application of Embolic protection device in CAS (IIa/C)
5. Non-invasive imaging follow-up is recommended at 1 month, 6 months, and annually after carotid CAS, including collateral vessel status, until the patient does not require further vascular intervention (IIa/C)
Management of restenosis after carotid artery reconstruction.
1, In symptomatic patients, restenosis revascularization is recommended (see original stenosis treatment criteria) (IIa/C)
2. In the course of follow-up, if restenosis is found to be progressing rapidly and may lead to total occlusion, CEA or CAS is recommended again (IIa/C)
3. In asymptomatic patients, consider revascularization of restenosis (see criteria for treatment of original stenosis) (IIb/C)
4. In those with restenosis <70% and asymptomatic, repeat CEA or CAS is not recommended (III/C)
Vertebral artery vasculopathy.
Imaging.
1, For symptomatic patients with subclavian artery steal, CTA and MRA are recommended as non-invasive imaging means to assess the posterior circulation (I/C)
2. For asymptomatic patients with bilateral carotid occlusion, unilateral carotid occlusion, or incomplete Willis rings, non-invasive impact examinations are recommended to detect vertebral artery stenosis (I/C)
3. For symptomatic patients, CTA, MRA, and not Doppler ultrasound are recommended as non-invasive imaging means to assess the posterior circulation (I/C)
4. For symptomatic patients, angiography is recommended prior to proposed revascularization (IIa/C)
5.For patients who have undergone vertebral artery revascularization, regular follow-up is recommended (same as carotid artery revascularization) (IIa/C)
Treatment strategy.
1.Recommend appropriate pharmacological and lifelong risk factor control treatment for vertebral artery vascular lesions (I/B)
2. Antiplatelet agents are recommended for patients with vertebral artery stenosis without contraindications, either aspirin 81-325 mg/d, aspirin combined with pansentin, or clopidogrel 75 mg (I/B)
Subclavian artery and head and arm vascular lesions.
1, posterior circulation ischemia caused by subclavian artery steal, carotid-subclavian artery bypass is recommended (IIa/B)
2. For posterior circulation ischemia caused by subclavian artery steal, interventional treatment is recommended when the surgical risk is high (IIa/C)
3.For symptomatic, head and arm vascular lesions, direct interventional revascularization or bypass surgery is recommended (IIa/C)
4.For inter-extremity claudication caused by subclavian artery lesions, direct interventional revascularization or bypass surgery (IIa/C) is recommended
5.If the subclavian artery is occluded and the ipsilateral internal mammary artery will be used for coronary artery bridging, direct interventional revascularization or bypass surgery is recommended (IIa/C)
6. Patients with asymptomatic subclavian artery stenosis, either with unequal blood pressure in the upper extremities, neck murmur, or vertebral artery reflux, are not recommended for revascularization, unless the internal mammary artery will be used for coronary artery reconstruction (III/C)