Best medical therapy as an alternative to surgery for borderline symptomatic carotid stenosis

BACKGROUND: According to several trials for patients with carotid symptomatic stenosis of 50-69% it is recommended an invasive treatment in order to prevent from recurrent ischemic cerebral events. However, for this subgroup the benefits of surgery have been demonstrated to be only marginal in stroke prevention and they remain unclear in women. Moreover, it is demonstrated that early surgery for symptomatic is accompanied by a high procedural risk of stroke/death less. In order to choose the optimal treatment we tried to evaluate whether medical therapy in this subgroup of patients could be an effective and safe approach. METHODS: The data have been collected retrospectively for each patient evaluated in vascular outpatients who suffered from any ischemic cerebral event and congruent carotid with 50-69% stenosis who did not receive an invasive treatment. Primary end points were considered ischemic recurrence, survival rate and carotid stenosis degree evolution during the follow-up. RESULTS: From January 2013 to January 2015 were identified 43 patients who suffered from ischemic cerebral lesion (TIA or stroke) and carriers of congruent carotid stenosis of 50-69% confirmed to both CT and duplex scan evaluation. The frequency of clinical and duplex scan evaluation was at 1 month after the discharge, at 3 months and every 6 months thereafter. Median follow-up was 36 months with at least 24-months follow-up for each patient. Mean age was 71 years (range: 60-83 years). In these patients medical therapy was undertaken within 12 hours from the onset of the symptomatology. In 32 patients was set up antiplatelet therapy and in 8 patients an anticoagulant therapy as atrial fibrillation was found out. In 2 patients was maintained the former anticoagulant therapy as they suffered from cardiac valvulopathy. Therapy with statins was set up in all patients despite dyslipidemia was found only in 55.8% of patients. Antihypertensive therapy was not necessary in 16%. In 12 patients with high blood homocysteine values was carried out a cyclic therapy with folate and group-B vitamins. Thirteen patients were smokers and it was strongly recommended cessation. The adherence to drug therapy was almost 100% unlike smoke cessation which was less than 50%. Mortality rate at 30 days was 2.3%. Recurrent ischemic event rate was 2.3% within 3 months and free from recurrences in the remaining duration of the follow-up. Carotid stenosis degree evolution more than 70% occurred in 4.6% and 6.9% respectively within 1 and 3 years and indication to CEA was given. CONCLUSIONS: In this study conservative management revealed to be a safe approach for patients with ischemic lesion and congruent carotid borderline stenosis in terms of mortality and preventing from recurrent cerebral ischemic events. Performing a strict clinical and instrumental surveillance in order to address selected patients to CEA increases the safety of medical approach.