The European Society for Vascular Surgery (ESVS) has just released 2023 clinical practice guidelines on the management of atherosclerotic carotid and vertebral artery disease. The guideline document, authored by chairperson Ross Naylor (Leicester Vascular Institute, Leicester, UK), co-chairperson Barbara Rantner (Ludwig Maximilian University of Munich, Munich, Germany) et al, was published online ahead of print in the European Journal of Vascular and Endovascular Surgery (EJVES).
The document contains 133 recommendations, including 38 that are new and 11 that have been ‘regraded’ since 2017, which is when the last ESVS guidelines on this topic were published. The manuscript contains 629 references, 289 of which are new (i.e. published between 2017 and 2022). Thirty-nine of the references are from randomised controlled trials, 71 are systematic reviews and/or meta-analyses, and the references also include data from 50 vascular registries or quality initiative programmes.
In the document, the authors first address what is new in the 2023 guidelines. They write that each section has been revised or rewritten and that five new sections have been added:
- Management of free floating thrombus
- Management of carotid webs
- Management of symptomatic patients with an ipsilateral 50–99% carotid stenosis and atrial fibrillation
- Planning carotid interventions in anticoagulated patients
- Timing of carotid interventions in patients with acute ischaemic stroke undergoing thrombolysis.
Naylor, Rantner and colleagues add that the new guidelines highlight similarities and discrepancies with the 2021 American Heart Association (AHA) guidelines on the management of stroke/transient ischaemic attack (TIA), the 2021 European Stroke Organisation (ESO) guidelines on carotid endarterectomy (CEA) and carotid artery stenting (CAS), the 2021 German-Austrian guidelines on the management of carotid disease, and the 2021 Society for Vascular Surgery (SVS) guidelines on the management of patients with carotid and vertebral artery disease.
In addition, the authors note that a series of unanswered questions in the 2017 guidelines were highlighted as being priorities for future research. “These involved scenarios where there were either no data, or conflicting evidence that did not allow recommendations to be made,” they elaborate. The current guidelines have addressed some of these questions, which include: Is there a validated algorithm for identifying ‘higher risk for stroke’ ACS [asymptomatic carotid stenosis] patients? Does ACS cause cognitive decline and can this be reversed or prevented by CEA or CAS? And which recently symptomatic patients with <50% stenosis might benefit from urgent CEA or CAS?
The guideline document, which is currently in press, can be found here.