New ESVS carotid guidelines: Key questions answered

L-R: Clark Zeebregts and Kosmas Paraskevas

Clark Zeebregts (University Medical Centre Groningen, Groningen, The Netherlands) and Kosmas Paraskevas (Central Clinic of Athens, Athens, Greece) answer some key questions about the 2023 European Society for Vascular Surgery (ESVS) clinical practice guidelines on the management of atherosclerotic carotid and vertebral artery disease.

What are the key takeaway messages from the 2023 document?

The 2023 ESVS carotid and vertebral guidelines highlight similarities and discrepancies with the 2021 American Heart Association (AHA) guidelines on the management of stroke/transient ischaemic attack (TIA), the 2021 European Stroke Organisation (ESO) guidelines on carotid endarterectomy (CEA) and carotid artery stenting (CAS), the 2021 German-Austrian Guidelines on the management of carotid artery disease and the 2021 Society for Vascular Surgery (SVS) guidelines on the management of patients with carotid and vertebral artery disease.

For patients with 60-99% asymptomatic carotid stenosis (AsxCS), the 2023 ESVS guidelines recognise the essential role of risk factor modification and best medical treatment (BMT). The recommendation that patients with 60-99% asymptomatic carotid stenosis and one or more clinical/imaging feature that make them higher risk for future stroke on BMT should be considered for CEA or CAS has been retained. For patients with recently symptomatic carotid artery stenosis (TIA or minor stroke), the ESVS guidelines strongly recommend expedited CEA to prevent recurrent cerebrovascular events, ideally within two weeks of the index event. The section on CAS techniques has been expanded to reflect technological advances since the 2017 ESVS guidelines. There is also an updated section on CAS/CEA after intracranial mechanical thrombectomy following an acute ischaemic stroke.

What is the significance of the timing?

The timing of carotid interventions after the onset of neurologic symptoms is crucial. There is evidence from natural history studies that the incidence of early recurrent stroke after a TIA episode range from 5-8% at 48 hours, 4-17% at 72 hours, 8-22% at seven days and 11-25% at 14 days. More recent studies that implemented BMT (including dual antiplatelet therapy and high-dose statins) report a lower prevalence of early recurrent neurologic symptoms following a TIA/minor stroke compared with observational cohorts. However, these studies may have included patient populations with lower risks of stroke compared with observational cohorts. The ESVS Guidelines Committee has therefore retained the target ‘two-week period’ for expedited CEA in patients with recent neurologic events.

How do these guidelines compare to the 2021 SVS guidelines?

There are two key differences between the 2023 ESVS and the 2022 SVS guidelines. The first difference is in the management of patients with AsxCS. According to the SVS guidelines, CEA in addition to BMT is strongly recommended over BMT alone in low-surgical risk patients with >70% AsxCS for the long-term prevention of stroke and death. In contrast, the ESVS guidelines identify specific clinical/imaging features associated with an increased risk of late ipsilateral stroke in patients with 60-99% AsxCS and recommend that a prophylactic carotid intervention should/may be considered in these individuals, provided their life expectancy exceeds five years and 30-day stroke/death rates are ≤3%.

The second key difference in the two guidelines is in the role of transcarotid artery revascularisation (TCAR). Based largely on the results reported in the Society for Vascular Surgery Vascular Quality Initiative (SVS-VQI), the SVS guidelines recommend TCAR over CEA and transfemoral CAS in ‘high surgical risk’ patients (both anatomically and physiologically). In contrast, although the 2023 ESVS guidelines recognise that TCAR has demonstrated some promising results, they are more reluctant to provide support for this novel method until more robust data are available.

What do the 2023 guidelines say about the role of TCAR?

The 2023 ESVS guidelines underline the fact that whilst TCAR has emerged as a promising new CAS technology since 2017, only one registry (the SVS-VQI) has reported outcomes stratified by delays from symptom onset to TCAR in symptomatic patients. This study showed that, when TCAR was performed within two days from the most recent symptom, in-hospital stroke and stroke/death rates were significantly higher than when TCAR was performed 3-14 days after the most recent symptom (in-hospital stroke: 5.6 % vs. 2.5%, for <2 vs. 3-14 days, respectively; odds ratio [OR]: 2.8; 95% confidence interval [CI]: 1.3-6.2; p=0.01, and in-hospital stroke/death: 6.5% vs. 2.9%, for <2 vs. 3-14 days, respectively; OR: 2.9; 95% CI: 1.3-6.4; p=0.01). The 2023 ESVS guidelines also highlighted the fact that the outcomes/efficacy of TCAR needs to be compared with CEA in a randomised controlled trial.

What questions remain unanswered in this field?

Some of the questions that remain unanswered in this field include:

  1. Should the 30-day thresholds for performing CEA/CAS in symptomatic (<6%) and asymptomatic (<3%) patients be reduced?
  2. Should the time threshold for a patient being defined as ‘recently symptomatic’ be reduced from the current definition of ‘six months’?
  3. Does severe asymptomatic carotid stenosis cause cognitive impairment and can carotid interventions either reverse or prevent cognitive decline?
  4. Are new ischaemic brain lesions after CEA or CAS associated with long-term cognitive impairment?
  5. Can TCAR be performed safely in the first 7-14 days after symptom onset with procedural risks similar to CEA?
  6. Is there a role for routine testing of antiplatelet ‘high on-treatment platelet reactivity (HTPR)’ (previously termed ‘antiplatelet resistance’) to guide adjustment of the regimen or dose of antiplatelet therapy?


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