Management outcomes in patients with carotid near occlusion

Background Cerebrovascular outcomes of carotid near occlusion (CNO) remain underreported. Current European guidelines advise against intervention in contrast to practice in the United States. Methods We conducted a PubMed search to include all English language publications to compare the early (30 day) and long-term stroke rate stratified by symptom status at presentation (symptomatic vs asymptomatic), treatment modality (BMT vs CEA vs CAS) as well as presence of Distal internal carotid artery (ICA) full collapse. Results A total of 61 studies reported results in 3,145 patients. There were 2,213 males (77%), and 2,503 (84%) were symptomatic at presentation. Among 1804 symptomatic patients, 1401 (78 %) underwent intervention [813 CEA (45%), 588 CAS (33%)] and BMT in 434 (22%). Early stroke was reported following CEA in 11 (1.3%) and CAS in 18 (3.1%) patients (p=0.035). At follow up (median 12 months), in symptomatic patients, overall stroke rates differed significantly between treatment strategies (BMT n=43, 10.7%; CEA n=35, 4.4%, CAS n=24, 4.1%; p < 0.001). Pairwise comparisons also demonstrated significantly higher stroke rates with BMT compared with either CEA or CAS (p <0.001), with no significant difference between the two interventional strategies (p=0.89). Among 165 asymptomatic patients, 134 (81%) underwent intervention [35 CEA (21%), 99 CAS (60%)] and BMT in 31 (19%). Early stroke was reported following CEA in 1 (2.9%) and CAS in 2 (2%) patients (p=1, not significant). On long term follow up (median 60 months), in asymptomatic patients, overall stroke rates did not differ significantly between treatment strategies (BMT n=0, 0%; CEA n=1, 2.9%; CAS n=2, 2%; p=0.66 not significant). Fifteen studies reported on Distal internal carotid artery collapse (394 patients); demographic details for these patients were not available, and only 13 mentioned the details of presentation [304 symptomatic (81%) vs 71 asymptomatic (19%)]. Results of intervention was reported in 14 studies, 131 patients (33%) underwent CEA, 151 (38%) underwent CAS, and 112 (29%) received BMT. Stroke rates were 4.8% (6/126) following CEA, 3.2% (4/126) following CAS, and 3.8% (3/80) with BMT (P=0.8). When revascularization (CEA+CAS) was analyzed collectively, the overall stroke rate was 4.9 (13/256) compared to 3.8 % (3/80) with BMT (P=0.83). Conclusions Symptomatic patients with CNO benefit from carotid intervention (CEA or CAS) in comparison to medical management alone while no clear benefit of intervention is observed in asymptomatic patients. Risks of intervention are also higher in those with Distal ICA collapse.