Laura Capoccia (Frosinone, Italy) writes about vascular surgeons’ role in acute stroke management and the importance of collaboration with other specialties in this setting.
While stroke treatment has dramatically changed in recent years, still around 795,000 people experience a new or recurrent stroke each year, and of all strokes 87% are ischaemic.1 A high variability in accessing stroke treatments exists across different countries or different regions within the same nation, even if at present guidelines are quite definitive in indicating endovenous thrombolysis and mechanical thrombectomy (MT) in selected cases as key treatment points. However, treatment indications are continuously evolving and so the vascular surgery world should be prepared to evolve accordingly. Looking back, the dawn of stroke treatment started with carotid revascularisation and, since historia magistra vitae (lessons for the future come from the past; Marcus Tullius Cicero, De Oratore), carotid treatment will continue to play a significant role in ischaemic stroke. Indeed, guidelines dating back to the end of the 1990s indicated carotid endarterectomy (CEA) as a procedure to consider in carotidrelated stroke patients, and some studies have demonstrated the possibility of CEA not only preventing recurrence of embolic neurological events (secondary prevention aim),2 but also of treating brain blood flow impairment when performed in acute patients (therapeutic aim).
It is also to be acknowledged that tandem or concurrent intracranial and extracranial (carotid) lesions are responsible for 10–20% of all large vessel occlusion strokes so that the issue of treating them simultaneously or not is at stake. Even if major societies’ guidelines still suggest that urgent symptomatic internal carotid artery (ICA) stenosis should be treated by CEA rather than by carotid artery stenting (CAS),3,4 the European Society for Vascular Surgery (ESVS) and the Society for Vascular Surgery (SVS) still concede that urgent CAS could be performed under certain conditions and the American Heart Association (AHA)/American Stroke Association (ASA) 2021 guidelines indicate treatment of tandem occlusions when performing MT as reasonable.5
Nowadays, following the publication of new trials’ results on wider time and lesion indications for MT, it is to be expected that the number of endovascular brain procedures will increase over time, and endovascular treatment of carotid lesions by CAS during MT in tandem lesions will increase accordingly, also taking into account the continuous evolution of techniques (different access routes and therapies) and devices (flow-reversal cerebral protection adjuncts, new meshcovered stents).
So, tandem lesions in stroke patients represents the possible meeting point between different specialties (neurology, neuroradiology, and vascular surgery) that should always work together to offer the best solution for patients, and, mimicking what happened at the beginning of the endovascular era when vascular surgeons started a close collaboration with interventionalists to acquire endovascular competencies, it could be time to start to involve vascular surgeons in endovascular brain procedures for the benefit of stroke patients. Acquiring specific competencies, certifications, and credentialling in devices and techniques for brain vessel treatment could be the next frontier and challenge for vascular surgery, thus bringing to patients’ care a new experience in managing complications after carotid treatment or in offering a direct carotid access route to MT.
References
- Tsao CW, Aday AW, Almarzooq ZI, et al. Heart disease and stroke statistics—2023 update: A report from the American Heart Association. Circulation 2023 Feb 21;147(8):e93–e621.
- Capoccia L, Sbarigia E, Speziale F, et al. Urgent carotid endarterectomy to prevent recurrence and improve neurologic outcome in mild-to-moderate acute neurologic events. J Vasc Surg 2011 Mar;53(3):622–7; discussion 627–8.
- Naylor R, Rantner B, Ancetti S, et al. Editor’s choice—European Society for Vascular Surgery (ESVS) 2023 clinical practice guidelines on the management of atherosclerotic carotid and vertebral artery disease. Eur J Vasc Endovasc Surg 2023; 65: 7–111.
- AbuRahma AF, Avgerinos ED, Chang RW, et al. Society for Vascular Surgery clinical practice guidelines for management of extracranial cerebrovascular disease. J Vasc Surg 2022; 75: 4S–22S.
- Kleindorfer DO, Towfighi A, Chaturvedi S, et al. 2021 guideline for the prevention of stroke in patients with stroke and transient ischemic attack: A guideline from the American Heart Association/American Stroke Association. Stroke 2021; 52: e364–e467.
Laura Capoccia is a vascular surgeon at “F. Spaziani” Hospital in Frosinone, Italy.
