What is the diagnosis for a 79-year-old male with irregular calcific plaque in the left carotid (Carotid Artery) bifurcation, mild plaque formation in the right carotid (Carotid Artery) bifurcation, and potential stenosis in the proximal right subclavian (Subclavian Artery) artery?

From the Guidelines

The patient should continue with medical management, including antiplatelet therapy (aspirin 81mg daily) and statin therapy (such as atorvastatin 40-80mg daily), and aggressive control of cardiovascular risk factors, as the current degree of stenosis is not severe enough to warrant surgical intervention. The carotid ultrasound shows mild to moderate narrowing in the left carotid artery (less than 50% stenosis) and mild plaque in the right carotid, along with possible right subclavian artery stenosis. The patient's condition is consistent with asymptomatic carotid stenosis, which has an annual stroke risk between 1% and 3.4% 1. Given the patient's age and the presence of carotid plaque, it is essential to monitor for progression of the carotid disease with regular follow-up ultrasounds (every 6-12 months). A CTA of the chest with IV contrast would be beneficial to evaluate the suspected right subclavian stenosis, which could potentially cause subclavian steal syndrome if severe, as recommended by the 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline 1. The guidelines for the primary prevention of stroke also emphasize the importance of managing asymptomatic carotid artery stenosis through medical management and lifestyle modifications 1. Key aspects of management include:

• Antiplatelet therapy to reduce the risk of stroke
• Statin therapy to manage cholesterol levels and reduce the risk of cardiovascular events
• Aggressive control of cardiovascular risk factors, including blood pressure, diabetes, and smoking cessation
• Regular follow-up ultrasounds to monitor for progression of the carotid disease
• Consideration of CTA or MRA to evaluate the severity of stenosis and identify intrathoracic or intracranial vascular lesions.

From the Research

Carotid Ultrasound Findings

• The patient's carotid ultrasound shows irregular calcific plaque with mild to moderate narrowing in the left carotid bifurcation and proximal ICA, but velocities do not suggest stenosis exceeding 50% 2, 3.
• Mild plaque formation is present in the right carotid bifurcation without dominant narrowing.
• Elevated systolic velocities of the proximal right subclavian artery suggest a possible proximal right subclavian stenosis, but this is not clearly depicted on the exam 3.

Recommendations for Further Assessment

• A CTA of the chest with IV contrast could be useful to further assess the proximal right subclavian artery for significant narrowing 3.
• Carotid ultrasound is a useful tool for risk stratification and can provide incremental value over traditional risk factors in predicting cardiovascular events 4, 5.
• The American Society of Echocardiography recommends standardization of focused 2D and 3D carotid arterial plaque ultrasound image acquisition and measurement for cardiovascular disease stratification 5.

Management of Carotid Stenosis

• Medical management of patients with carotid stenosis is always warranted and should include correction of cardiovascular risk factors, such as lifestyle intervention and pharmacological treatment 2, 3.
• The use of antiplatelet therapy, statins, and ACE inhibitors is recommended as part of a tri-therapy strategy for patients with carotid stenosis 2, 3.
• Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are options for symptomatic patients with stenosis >50% and for asymptomatic patients with tight stenosis (>60%) and a perceived high long-term risk of stroke 3.