Highlights sulle nuove LG europee per la patologia carotidea

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Post di Gaetano Lanza

Pubblicate da poco su EJVES. Sono le nuove Linee Guida della Società Europea di Chirurgia Vascolare sulla patologia carotidea ( co-chairmen Naylor e Ricco, tra i co-autori il nostro Fabio Verzini) che alleghiamo.

LG ESVS Carotidi 2017

Abbiamo qui di seguito selezionato alcune Raccomandazioni secondo noi più meritevoli (opinione discutibile). Vale la pena ovviamente leggere nell’allegato anche le altre che qui non riportiamo.

Routine population screening for asymptomatic carotid stenosis is not recommended III C

Selective screening for asymptomatic carotid stenoses may be considered in patients with multiple vascular risk factors to optimise risk factor control and medical therapy to reduce late cardiovascular morbidity and mortality, rather than for identifying candidates for invasive carotid interventions  IIb C

Patients who are to undergo revascularisation within the first 14 days after onset of symptoms should undergo carotid endarterectomy, rather than carotid stenting   I A

In “average surgical risk” patients with an asymptomatic 60 99% stenosis, carotid endarterectomy should be considered in the presence of one or more imaging characteristics that may be associated with an increased risk of late ipsilateral stroke, provided documented perioperative stroke/death rates are <3% and the patient’s life expectancy exceeds 5 years  IIa B

In “average surgical risk” patients with an asymptomatic 60 99% stenosis in the presence of one or more imaging characteristics that may be associated with an increased risk of late ipsilateral stroke, carotid stenting may be an alternative to carotid endarterectomy, provided documented perioperative stroke/death rates are <3% and the patient’s life expectancy exceeds 5 years IIb B

Carotid stenting may be considered in selected asymptomatic patients who have been deemed by the multidisciplinary team to be high-risk for surgery and who have an asymptomatic 60 e 99% stenosis in the presence of one or more imaging characteristics that may be associated with an increased risk of late ipsilateral stroke,  provided documented procedural risks are <3% and the patient’s life expectancy exceeds 5 years  IIb  B

Revascularisation should be deferred in patients with 50 e 99% stenoses who suffer a disabling stroke (modified Rankin score >3), whose area of infarction exceeds one-third of the ipsilateral middle cerebral artery territory, or who have altered consciousness/drowsiness, to minimise the risks of postoperative parenchymal haemorrhage I C

Patients with 50e99% stenoses who present with stroke-in evolution or crescendo transient ischaemic attacks should be considered for urgent carotid endarterectomy, preferably <24 hours IIa C

Early carotid endarterectomy (within 14 days) should be considered after intravenous thrombolysis in symptomatic patients if they make a rapid neurological recovery (Rankin 0 e 2), the area of infarction is less than one-third of the ipsilateral middle cerebral artery territory, a previously occluded middle cerebral artery mainstem has recanalised, there is a 50e99% carotid stenosis and no evidence of parenchymal haemorrhage or significant brain oedema IIa C

Carotid endarterectomy or carotid stenting may be considered in recently symptomatic patients with <50% stenoses if they suffer recurrent symptoms despite best medical therapy and following multidisciplinary team review IIb C

It is recommended that the choice of shunting (routine, selective, never) be left to the discretion of the operating surgeon  I C

Routine patching is recommended, rather than routine primary closure I A

Eversion endarterectomy is recommended over routine primary arteriotomy closure. The choice between eversion or patched endarterectomy should be left to the discretion of the operating surgeon  I A

Surgical intervention for asymptomatic isolated coils/kinks of the internal carotid artery is not recommended.  III C

Symptomatic patients with isolated coils/kinks may be considered for surgical correction, but only following multidisciplinary team review and provided no other cause for transient ischaemic attack or stroke symptoms can be identified. IIb B

Proximal protection devices are not recommended in patients with advanced common carotid disease, or those with external carotid artery disease (where an occlusion balloon is to be positioned in the external carotid artery) or in patients with contralateral occlusion and insufficient collateralisation III C

Patch excision and autologous venous reconstruction is recommended for most patients with prosthetic patch infection.  I C

Insertion of a covered stent may be considered in selected high-risk for surgery” patients with suspected prosthetic patch infection  IIb C

Patients suffering a late ipsilateral stroke/TIA in the presence of an ipsilateral 50e99% restenosis should undergo redo carotid endarterectomy or carotid artery stenting.  I A

It is recommended that carotid stent patients who develop an asymptomatic restenosis >70% are treated medically. I A

Routine screening for carotid disease prior to open-heart surgery is not recommended. III C

The choice between carotid endarterectomy and carotid stenting in asymptomatic patients in whom a carotid intervention is deemed necessary prior to coronary artery bypass should be based on the urgency of performing surgery, choice of antiplatelet strategy during coronary bypass, individual patient characteristics, symptom status, and local expertise. IIa C

Prophylactic carotid endarterectomy and carotid stenting are not recommended in patients with asymptomatic carotid stenoses prior to major non-cardiac, non-vascular surgical procedures. III B

Open or endovascular interventions to treat proximal common carotid artery or innominate artery stenoses/occlusions are not recommended in asymptomatic patients III C

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