"Choosing wisely"-Recommendations on extracranial carotid stenosis

Background. The Association of the Scientific Medical Societies in Germany (AWMF) implemented a committee on the subject of choosing wisely together based on an initiative of the American Committee on Internal Medicine (ABIM). Methods. Based on the German-Austrian guidelines for the diagnosis, treatment and follow-up of extracranial carotid stenosis and the choosing wisely together recommendations of the German Society for Internal Medicine (DGIM), four positive and four negative choosing wisely together recommendations were developed. Defined criteria from the AWMF were considered. Results. Any carotid intervention should be preceded by guideline-based clinical and imaging diagnostics. All patients treated by carotid endarterectomy (CEA) or carotid artery stenting (CAS) should receive periprocedural best medical treatment. In 50-99% of symptomatic carotid stenoses patients should be treated by CEA within 14 days after the index neurological event. Invasive treatment of high-grade asymptomatic carotid stenosis should only be performed if clinical or morphological features are associated with an increased risk of stroke in the follow-up period. Routine ultrasound screening for carotid artery stenosis should not be performed. CEA and CAS should not be performed in centers with low volume and lack of guidelinebased hospital infrastructure. High-grade asymptomatic carotid stenosis should not be treated in hospitals with a periprocedural stroke/death risk >2%. Symptomatic carotid stenosis should not be treated in hospitals with a periprocedural stroke/death risk > 4%. Conclusions. Following these evidence-based positive and negative recommendations can contribute to a rational and cost-effective resource-friendly management of extracranial carotid stenosis in Germany.