Newly issued guidelines provide increased support for carotid stenting as an alternative to carotid endarterectomy, but don’t favor widespread screening or the routine use of ultrasound to assess the risk for stroke. The Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease, developed by the AHA, the ACC, and multiple other organizations, is published online in Circulation, Stroke,and JACC.

Both stenting and endarterectomy are acceptable when blockages are greater than 50%, according to the guidelines, but medical therapy may be preferable for many patients. “The guidelines support carotid surgery as a tried-and-true treatment for most patients,” said Thomas G. Brott, co-chair of the writing committee, in a press release. “However, for patients who have a strong preference for less invasive treatments, carotid stenting offers a safe alternative. Because of the anatomy of their arteries or other individual considerations, some patients may be more appropriate for surgery and others for stenting.”

“The risks of these procedures have fallen considerably, but you need to make sure you have very experienced practitioners performing the latest techniques,” said Jonathan Halperin, the other co-chair.

Although widespread screening is not endorsed in the new guidelines, Halperin said that screening is reasonable in people with two or more risk factors for stroke.

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Here is the AHA press release:

Test for blocked neck arteries only necessary for people with stroke risk factors

DALLAS, Jan. 31, 2011 — Widespread screening or routine ultrasound for blocked neck arteries to determine stroke risk isn’t necessary, according to new guidelines from the American Heart Association/American Stroke Association, American College of Cardiology and other groups.

Carotid stenting and carotid endarterectomy are reasonable and effective ways to treat blocked neck arteries, though some patients may be a better candidate for one procedure over the other, the guidelines also state.

When the carotid arteries on the side of the neck or vertebral arteries alongside the spinal column become clogged, less blood gets to the brain and the risk of stroke increases.

The guidelines writing committee, which included a wide range of specialists on stroke prevention, agreed there isn’t sufficient evidence of benefit for widespread screening. “However, if your doctor hears abnormal blood flow when listening to your neck arteries, or if you have two or more risk factors for stroke (such as high cholesterol or a family history), then it is a reasonable approach,” said Jonathan L. Halperin, M.D., co-chair of the writing committee and Professor of Medicine at the Mount Sinai School of Medicine in New York.

“The guidelines will provide new information and evidence to help clinicians select treatment approaches with their patients,” said Thomas G. Brott, M.D., committee co-chair, Professor of Neurology and director of research at the Mayo Clinic campus in Jacksonville, Fla.

Stroke risk factors include age, family history of stroke, high blood pressure, high blood cholesterol, diabetes, obesity, atrial fibrillation, physical inactivity, sickle cell disease and other heart or blood vessel diseases.

Among dozens of recommendations, the writing group also noted that two often competing procedures are used to restore adequate blood flow to the brain past severely narrowed arteries. In carotid endarterectomy, used for half a century, plaque buildup is surgically removed. In stenting, which has been available for about 15 years, a balloon catheter is inserted to open the vessel and a metal mesh tube (stent) is left in place to keep the blood vessel open.

After reviewing the evidence, including two recent head-to-head comparisons, the writing committee concluded that both approaches are reasonable and safe when arteries are more than 50 percent blocked.

“The guidelines support carotid surgery as a tried-and-true treatment for most patients,” Brott said. “However, for patients who have a strong preference for less invasive treatments, carotid stenting offers a safe alternative. Because of the anatomy of their arteries or other individual considerations, some patients may be more appropriate for surgery and others for stenting.”

Furthermore, medications offer a better alternative than either surgery or stenting for many patients, according to the guidelines. In the latest clinical trials comparing the procedures, all patients received optimal medical treatment and there were no medication-only groups.

“The risks of these procedures have fallen considerably, but you need to make sure you have very experienced practitioners performing the latest techniques,” Halperin said.

The guidelines will be published in Circulation: Journal of the American Heart Association; Stroke: Journal of the American Heart Association, and Journal of the American College of Cardiology.

The guidelines were developed with the American Association of Neuroscience Nurses; American Association of Neurological Surgeons; American Society of Neuroradiology; American College of Radiology; Congress of Neurological Surgeons; Society for Atherosclerosis Imaging and Prevention; Society for Cardiovascular Angiography and Interventions; Society of Interventional Radiology; Society for NeuroInterventional Surgery; Society for Vascular Medicine; and Society for Vascular Surgery.

The American Academy of Neurology and the Society of Cardiovascular Computed Tomography collaborated in the process.