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Purpose of ReviewProvide a current overview regarding the optimal strategy for managing patients with asymptomatic carotid artery stenosis.Recent FindingsCarotid endarterectomy (CEA) and carotid artery stenting (CAS) reduce long-term stroke risk in asymptomatic patients. However, CAS is associated with a higher risk of peri-procedural stroke. Improvements in best medical therapy (BMT) have renewed uncertainty regarding the extent to which results from older randomised controlled trials (RCTs) comparing outcomes following carotid intervention can be generalised to modern medical practise.Summary‘Average surgical risk’ patients with an asymptomatic carotid artery stenosis of 60–99% and increased risk of late stroke should be considered for either CEA or CAS. In patients deemed ‘high risk’ for surgery, CAS is indicated. Use of an anti-platelet, anti-hypertensive and statin, with strict glycaemic control, is recommended. Results from ongoing large, multicentre RCTs comparing CEA, CAS and BMT will provide clarity regarding the optimal management of patients with asymptomatic carotid artery stenosis.

BackgroundStandardisation of referral pathways and the transfer of patients with acute aortic syndromes (AAS) to regional centres are recommended by NHS England in the Acute Aortic Dissection Toolkit. The aim of the Transfer of Thoracic Aortic Vascular Emergencies to Regional Specialist INstitutes Group study was to establish an interdisciplinary consensus on the interhospital transfer of patients with AAS to specialist high-volume aortic centres.MethodsConsensus on the key aspects of interhospital transfer of patients with AAS was established using the Delphi method, in line with Conducting and Reporting of Delphi Studies guidelines. A national patient charity for aortic dissection was involved in the design of the Delphi study. Vascular and cardiothoracic surgeons, emergency physicians, interventional radiologists, cardiologists, intensivists and anaesthetists in the United Kingdom were invited to participate via their respective professional societies.ResultsThree consecutive rounds of an electronic Delphi survey were completed by 212, 101 and 58 respondents, respectively. Using predefined consensus criteria, 60 out of 117 (51%) statements from the survey were included in the consensus statement. The study concluded that patients can be taken directly to a specialist aortic centre if they have typical symptoms of AAS on the background of known aortic disease or previous aortic intervention. Accepted patients should be transferred in a category 2 ambulance (response time <18 min), ideally accompanied by transfer-trained personnel or Adult Critical Care Transfer Services. A clear plan should be agreed in case of a cardiac arrest occurring during the transfer. Patients should reach the aortic centre within 4 hours of the initial referral from their local hospital.ConclusionsThis consensus statement is the first set of national interdisciplinary recommendations on the interhospital transfer of patients with AAS. Its implementation is likely to contribute to safer and more standardised emergency referral pathways to regional high-volume specialist aortic units.

Background: Successful carotid endarterectomy (CEA) and carotid artery stenting (CAS) halve long-term stroke risk but are potentially hazardous. Optimising the carotid intervention pathway may reduce harm. Aims: This thesis used qualitative and quantitative methodologies to identify: hospital-level factors affecting CEA and CAS procedural outcomes; failures in the CEA pathway for improvement; temporal and regional trends in CEA and CAS provision and outcomes; and patient-level factors affecting procedural and long-term outcomes. Qualitative Methods and Results: A systematic review of 124,958 patients showed that large hospitals, serving large populations, with vascular beds, clinical pathways and Vascular Surgeons performing CEA were associated with improved outcomes. An ethnographic study, involving 1,072 hours of observations of the CEA pathway in symptomatic patients, identified 110 patient safety incidents primarily in documentation, public health awareness and the care-providing environment. A Healthcare Failure Mode and Effect Analysis of 65 organisational failures by 13 stakeholders recommended patient education to improve stroke recognition, increasing resources, implementing technology, standardising care and improving communication to optimise the CEA pathway. Quantitative Methods and Results: A 16-year analysis of 68,897 English patients in the Hospital Episode Statistics dataset showed that CEA and CAS age-standardised rates reduced since 2011-2012 with regional variation in provision. Despite temporal improvements in most CEA procedural outcomes, regional variation existed in CEA and CAS outcomes. Prior stroke and congestive heart failure were associated with adverse CEA and CAS procedural outcomes whilst ischaemic heart disease, peripheral vascular disease, diabetes mellitus, chronic renal failure, age 70 years and above and non-White ethnicity were associated with increased CEA risk. Increased deprivation was associated with CEA mortality but did not affect CAS outcomes. Similar risk factors existed for long-term stroke risk following CEA and CAS. Conclusions: Organisational and patient-level factors have been identified for optimising the carotid intervention pathway. Implementing these findings may reduce harm in high-risk patients undergoing carotid interventions, maximising their effectiveness.