Why selective screening for asymptomatic carotid stenosis is currently appropriate: a special report

ABSTRACT

Introduction

Two of the main reasons recent guidelines do not recommend routine population-wide screening programs for asymptomatic carotid artery stenosis (AsxCS) is that screening could lead to an increase of carotid revascularization procedures and that such mass screening programs may not be cost-effective. Nevertheless, selective screening for AsxCS could have several benefits. This article presents the rationale for such a program.

Areas covered

The benefits of selective screening for AsxCS include early recognition of AsxCS allowing timely initiation of preventive measures to reduce future myocardial infarction (MI), stroke, cardiac death and cardiovascular (CV) event rates.

Expert Opinion

Mass screening programs for AsxCS are neither clinically effective nor cost-effective. Nevertheless, targeted screening of populations at high risk for AsxCS provides an opportunity to identify these individuals earlier rather than later and to initiate a number of lifestyle measures, risk factor modifications, and intensive medical therapy in order to prevent future strokes and CV events. For patients at ‘higher risk of stroke’ on best medical treatment, a prophylactic carotid intervention may be considered.

KEYWORDS:

• Asymptomatic carotid atherosclerosis
• carotid plaque burden
• carotid stenosis
• guidelines
• screening
• stroke

Article highlights

• Population-wide screening for asymptomatic carotid stenosis by duplex ultrasound is neither clinically efficient nor cost-effective.

• Current international guidelines (e.g. the 2022 Society for Vascular Surgery and the 2023 European Society for Vascular Surgery guidelines) do not recommend population-wide screening programs for asymptomatic carotid stenosis.

• Selective screening of ‘high-risk’ patient subgroups may be beneficial for the timely identification of individuals with ≥50% asymptomatic carotid stenosis.

• Early identification of individuals with asymptomatic carotid stenosis may lead to prompt initiation of preventive measures to reduce the high myocardial infarction and cardiovascular event rates, including stroke, in these patients.

• For patients at ‘higher risk of stroke’ on best medical treatment, a prophylactic carotid intervention may be considered.

Conflicts of interest

Marc L. Schermerhorn, is the Principal Investigator of the ROADSTER-3 trial and is the Chair of the TCAR Surveillance Program in the Vascular Quality Initiative. Martin M. Brown is co-Principal Investigators for the 2nd European Carotid Surgery Trial (ECST-2). Peter Schneider is a consultant for Silk Road, Philips, Surmodics, Medtronic, Boston Scientific, Agent and Acotec. Eric A. Secemsky, has received research grants from the Food & Drug Administration (FDA), SCAI, BD, Boston Scientific, Cook, Laminate Medical, Medtronic, Philips, and NIH/NHLBIK23HL150290. He has received Consulting/Speaker fees from Abbott, Bayer, BD, Boston Scientific, Cook, Cordis, Heartflow, Inari, InfraRedx, Medtronic, Philips, RapidAI, Shockwave, and VentureMed. William A. Gray is a Consultant for Contego Medical, InspireMD, Medtronic, and Boston Scientific and has received institutional research support for Contego Medical and CREST-2. Clark J. Zeebregts has received consulting, research support, honoraria, and travel support from W.L. Gore & Associates, LeMaitre Vascular, Atrium Maquet Getinge Group, Artivion, Terumo (Vaskutek and Bolton) and Cook Medical. Brajesh K. Lal is co-Principal Investigator of the CREST-2 multicenter randomized clinical trial (U01NS080168), Principal Investigator of the CREST-2 Registry (C2R; NCT02240862) and Principal Investigator for the Asymptomatic Carotid Stenosis and Cognitive Function Study (ACCOF; CX001621). The other authors have no conflicts of interest. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from thosea disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.