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On behalf of the steering group of the clinical practice guideline I wish to thank our correspondent for his important comment. It is correct that high-grade asymptomatic carotid stenoses are associated with a higher stroke risk than medium-grade stenoses. It should be borne in mind in this context, however, that improvements to the medical treatment of atherosclerosis have overall brought about a reduction in the carotid-associated stroke risk. A general recommendation to initiate revascularization from >70% stenosis (according to the criteria of the German Society for Ultrasound in Medicine [DEGUM]) is thus no longer justified.

Since 15% of all ischemic strokes in the anterior circulation are caused by an extracranial carotid lesion, it is important to distinguish patients at higher stroke risk from patients with a lower stroke risk. Regarding this question, clinical and morphological variables have been identified in recent years that in the presence of asymptomatic carotid stenosis indicate an increased stroke risk (Table 3) (1).

The updated S3 guideline therefore recommends that for 60–99% clinically asymptomatic carotid stenoses, carotid endarterectomy [CEA] should be considered, if the surgical risk is not increased and one or more imaging results are available that are associated with an increased risk of carotid-related stroke risk during follow-up (Table 1). This means that in addition to the finding of a higher-grade carotid stenosis, at least one further clinical or morphological criterion has to be met in order to assume a relevant carotid-associated stroke risk over the further course.

Our recommendations seek to help identify those “carotid patients” who would benefit in the long term from surgical (if needed, endovascular) stroke prevention combined with best medical prevention therapy. In this sense, the current recommendations constitute a contribution to the personalized management of asymptomatic carotid stenoses.

DOI: 10.3238/arztebl.m2021.0146

On behalf of the authors

Prof. Dr. med. Hans Henning Eckstein

Klinik für Vaskuläre und Endovaskuläre Chirurgie

Klinikum rechts der Isar der Technischen Universität München

HHEckstein@web.de

Conflict of interest statement

The authors of both letters to the editor declare that no conflict of interest exists.

1.
Eckstein HH, Kühnl A, Berkefeld J, Lawall H, Storck M, Sander D: Clinical practice guideline: Diagnosis, treatment and follow-up in extracranial carotid stenosis. Dtsch Arztebl Int 2020; 117: 801–7 VOLLTEXT
1.Eckstein HH, Kühnl A, Berkefeld J, Lawall H, Storck M, Sander D: Clinical practice guideline: Diagnosis, treatment and follow-up in extracranial carotid stenosis. Dtsch Arztebl Int 2020; 117: 801–7 VOLLTEXT

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