Updated SVS Clinical Practice Guidelines Address Carotid Artery Disease

July 1, 2021—The Society for Vascular Surgery (SVS) announced that updated clinical practice guidelines on managing patients with extracranial cerebrovascular disease have been published by Ali F. AbuRahma, MD, et al in Journal of Vascular Surgery.

The guidelines are accompanied by an implementation document for the management of patients with extracranial cerebrovascular disease by Dr. AbuRahma et al, also published online ahead of print in Journal of Vascular Surgery.

According to SVS, the documents aim to use the existing clinical evidence to ensure patients with atherosclerotic occlusive disease in the carotid arteries receive appropriate treatment and care.

The press release noted that the clinical significance of carotid artery stenosis is mainly related to its prevalence and its potential to cause stroke, defined as partial or global loss of brain neurologic function from blood supply interruption, or transient ischemic attacks, defined in a similar manner but with symptom resolution in < 24 hours. Therapeutic options for carotid artery disease include medical therapy optimization, carotid endarterectomy (CEA), or endovascular treatment with carotid artery stenting (CAS). Extensive research has resulted in the development of evidence to guide treating physicians toward the appropriate type and timing of intervention depending on the degree of carotid disease, the presence of neurologic symptoms, and the patient’s comorbidities.

The announcement noted that SVS’s previous update of the clinical practice guidelines for carotid artery disease was published in 2011. Since then, several pivotal studies comparing CEA and CAS have been published. In addition, the literature has demonstrated confirmation of the need for optimization of medical therapy.

Therefore, the updated SVS guidelines provide graded recommendations that address five issues:

• The role of surgical therapy over medical therapy alone in asymptomatic low-risk patients
• The role of CEA versus CAS in symptomatic low-risk patients
• The optimal timing of interventions after acute stroke
• Screening for carotid artery stenosis in asymptomatic patients
• The sequence of carotid and coronary interventions in patients undergoing intervention for diseases in both vascular territories

Dr. AbuRahma, chair of the writing group, commented in the SVS press release, “These guideline recommendations address the latest technology in the management of carotid disease, such as transcarotid artery stenting with flow reversal and how its outcomes compare to transfemoral stenting and the gold-standard, CEA."

The writing group also identified additional topics that needed to be addressed in more detail, which they do in the separate implementation document. These topics include details about therapeutic decision-making; perioperative management; medical therapy; other cerebrovascular conditions; and practice management. This document is intended to make the guidelines more practical and helpful to clinicians and provides implementation details to facilitate adoption and operationalization of the guideline recommendations, stated SVS.

“The advantage of two documents is having quick access to evidence-based recommendations in the clinical practice guideline, while also having the implementation document, which comprehensively addresses every aspect of the management of carotid disease and stroke prevention,” noted Dr. AbuRahma in the SVS announcement.