From the Guidelines
Intervention for carotid artery stenosis is recommended for symptomatic patients with stenosis ≥70% and for those with 50-69% stenosis if the procedural risk is low, as stated in the 2024 ESC guidelines 1.
Indications for Intervention
The decision to intervene is based on the degree of stenosis, symptoms, and procedural risk.
- Symptomatic patients with severe stenosis (70-99%) should undergo carotid endarterectomy (CEA) if the 30-day risk of procedural death/stroke is <6% 1.
- For symptomatic patients with moderate stenosis (50-69%), CEA may be considered if the procedural risk is low 1.
- Carotid artery stenting (CAS) is an alternative to CEA for symptomatic patients at high risk for surgery or with specific anatomical considerations 1.
Procedural Timing and Risk
- Intervention should be performed within 14 days of symptom onset for maximum benefit 1.
- The procedural risk should be carefully assessed, and intervention is not recommended if the risk of death or stroke exceeds 6% 1.
Medical Therapy
All patients with carotid artery stenosis should receive optimal medical therapy, including:
- Antiplatelet agents (aspirin or clopidogrel) 1
- Statins (high-intensity) 1
- Blood pressure control (target <140/90 mmHg) 1
- Lifestyle modifications 1
Patient-Specific Factors
Patient-specific factors, such as age, sex, comorbidities, and anatomical considerations, influence the decision to intervene and the choice of procedure 1.
From the Research
Indications for Intervention
The indications for intervention for carotid artery stenosis can be summarized as follows:
- Symptomatic carotid artery disease with 70-99% luminal narrowing should be treated with intensive medical therapy and considered for revascularization with either carotid endarterectomy or carotid angioplasty and stenting 2
- Asymptomatic carotid artery stenosis with ≥70% stenosis may be considered for revascularization with carotid endarterectomy or carotid angioplasty and stenting, although the benefit is less clear and may depend on individual patient factors 3, 4, 5
Diagnostic Criteria
Diagnostic criteria for ≥70% internal carotid artery stenosis include:
- Peak systolic velocity >130 cm/sec and end-diastolic velocity >100 cm/sec on color-flow duplex scanning 6
- Internal carotid arteries with peak systolic velocity <40 cm/sec in which only a trickle of flow could be detected may be classified as preocclusive lesions (95% to 99% stenosis) 6
Treatment Options
Treatment options for carotid artery stenosis include: