From the Guidelines
Carotid web treatment should prioritize antiplatelet therapy as the first-line treatment, with surgical intervention considered for patients with recurrent ischemic stroke or TIA despite medical management, as recommended by the American Heart Association/American Stroke Association guideline 1. The treatment approach for carotid webs depends on various factors, including symptom severity, stroke risk, and patient characteristics.
- For patients with carotid web in the distribution of ischemic stroke and TIA, without other attributable causes of stroke, antiplatelet therapy is recommended to prevent recurrent ischemic stroke or TIA 1.
- In patients with carotid web in the distribution of ischemic stroke refractory to medical management, with no other attributable cause of stroke despite comprehensive workup, carotid stenting or CEA may be considered to prevent recurrent ischemic stroke 1. Additionally, recent guidelines suggest that prescribing triple medical therapy, including anti-thrombotic, anti-hypertensive, and LDL-C–lowering drugs, can reduce the risk of stroke, MI, and death in patients with carotid atherosclerotic disease 1.
- Intensive statin therapy, with ezetimibe or a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor as an alternative or adjunctive therapies, aiming to achieve an LDL-C < 55 mg/dL, is advised for all patients with significant carotid atherosclerotic disease 1. The decision between carotid endarterectomy (CEA) and carotid artery stenting (CAS) depends on patient factors, anatomical considerations, and local surgical expertise.
- CEA involves direct surgical removal of the web through an incision in the neck, while CAS is less invasive and uses a catheter to place a stent that flattens the web against the arterial wall. Treatment is essential because carotid webs create turbulent blood flow that promotes thrombus formation, significantly increasing stroke risk, particularly in younger patients without traditional vascular risk factors.
- Following intervention, patients typically continue antiplatelet therapy for at least several months, with regular ultrasound follow-up to monitor for recurrence or complications.
From the Research
Carotid Web Treatment Options
- Carotid webs are a rare cause of ischemic strokes, particularly in young people, and are characterized by a shelf-like intraluminal projection in the carotid bulb 2.
- Treatment options for symptomatic carotid webs include interventional therapy with carotid endarterectomy or carotid stenting, as well as medical therapy with antiplatelet or anticoagulants 3.
Interventional Management
- Carotid revascularization is a safe and effective option for preventing recurrent ischemic events in patients with symptomatic carotid webs, with no periprocedural mortality and low rates of major complications 3.
- Endarterectomy and stenting are the most commonly used interventional procedures for carotid web treatment, with stenting being used in approximately 60% of cases and endarterectomy in approximately 40% of cases 3.
Medical Management
- Antiplatelet therapy is commonly used to manage asymptomatic and symptomatic carotid webs, with aspirin being the most frequently used medication 4, 5.
- Anticoagulants are also used in some cases, particularly for patients with recurrent strokes or other high-risk features 5.
- However, medical management is associated with a higher recurrence rate of stroke after the index event, highlighting the need for alternative treatment strategies 2.
Diagnostic Imaging
- Computed tomography angiography is the most commonly used imaging modality to diagnose carotid webs, due to its high sensitivity and specificity 2, 5.
- Conventional digital subtraction angiogram is also used to confirm the presence of a carotid web, particularly in cases where the diagnosis is uncertain 5.
Current Practice and Guidelines
- There is currently a lack of evidence-based treatment guidelines for carotid webs, leading to variability in clinical practice across different subspecialties 5.
- Ongoing multicenter registries and studies are needed to guide management decisions and develop standardized treatment protocols for carotid web patients 2.