2017 European Society for Vascular Surgery guidelines for management of carotid and vertebral artery disease - Journal of Vascular Surgery

Old debates, the fallacy of revisionist history, and transatlantic differences in clinical decision-making referable to carotid bifurcation atherosclerosis are highlighted in the newly published 2017 European Society for Vascular Surgery (ESVS) guidelines.1x1Writing Group, Naylor, A.R., Ricco, J.B., de Borst, G.J., Debus, S., de Haro, J. et al. Management of atherosclerotic carotid and vertebral artery disease: 2017 clinical practice guidelines of the European Society for Vascular Surgery (ESVS) [published online ahead of print]. Eur J Vasc Endovasc Surg. August 26, 2017; https://doi.org/10.1016/j.ejvs.2017.06.021 Abstract | Full Text | Full Text PDF | PubMed | Scopus (19) | Google ScholarSee all References The document itself is ponderous, running some 80 pages and inclusive of nearly 500 references; indeed, I found it a wonderful reference document. The Special Communication article of Paraskevas et al2x2Paraskevas, K.I., Ricco, A.B., and Veith, F.J. Seeing light and shadows: a commentary on the 2017 European Society for Vascular Surgery carotid guidelines. J Vasc Surg. 2018; 67: 646–648 Abstract | Full Text | Full Text PDF | Scopus (2) | Google ScholarSee all References published in this issue of the Journal of Vascular Surgery is a useful guide to discern differences in the current ESVS guideline that might be compared, for example, with the widely quoted American Heart Association and Society for Vascular Surgery guidelines. Even somewhat amusing is the resurrection of the carotid artery stenting (CAS) as an alternative (typically considered in some quarters to mean equivalent) to carotid endarterectomy (CEA) language; at least in symptomatic patients, the 2017 ESVS guideline strongly endorses CEA (vs CAS) as the preferred intervention in the majority of patients. This is, in turn, aligned with the recommendations to proceed with CEA within 2 weeks of the index neurologic event and the related and compelling information that transfemoral CAS in this setting has unacceptable neurologic complication rates. Moving beyond prior guidelines in its consideration of asymptomatic patients, the 2017 ESVS document attempts to define subgroups of patients (solely on the basis of imaging characteristics) who might be at increased stroke risk and thereby benefit from an intervention beyond medical therapy. In distinction to virtually all extant guidelines, the new document makes no strong consideration with respect to degree of stenosis or fundamental clinical characteristics, such as the patient's age. However, the algorithm for decision-making in asymptomatic