What are the treatment options for carotid artery stenosis?

From the Guidelines

Carotid artery stenosis treatment should be individualized based on the patient's overall health status, life expectancy, and preferences, with a focus on reducing morbidity, mortality, and improving quality of life. The treatment approach depends on the severity of narrowing, symptoms, and patient risk factors. For asymptomatic patients with mild to moderate stenosis (less than 50-60%), medical management is typically recommended, including antiplatelet therapy (aspirin 81-325 mg daily or clopidogrel 75 mg daily), high-intensity statin therapy (atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily), blood pressure control (target <140/90 mmHg), smoking cessation, and diabetes management 1.

Key Considerations

• For symptomatic patients with moderate to severe stenosis (>50%) or asymptomatic patients with severe stenosis (>70-80%), surgical intervention may be warranted, with carotid endarterectomy (CEA) being the gold standard surgical procedure, involving removal of plaque from the artery 1.
• Carotid artery stenting (CAS) is an alternative for patients at high surgical risk, with the choice between CEA and CAS depending on patient age, anatomy, comorbidities, and surgical risk 1.
• Post-procedure, patients require lifelong antiplatelet therapy and aggressive risk factor modification, with treatment decisions being individualized based on the patient's overall health status, life expectancy, and preferences 1.

Recent Guidelines

• The 2024 ESC guidelines recommend optimal medical treatment for all symptomatic patients with carotid stenosis, with CEA being considered for patients with moderate (50%–69%) and severe (70%–99%) stenosis, and CAS being considered for patients at high surgical risk 1.
• The guidelines also emphasize the importance of individualizing treatment decisions based on patient-specific factors, such as age, comorbidities, and surgical risk.

Quality of Life Considerations

• Treatment decisions should prioritize reducing morbidity, mortality, and improving quality of life, with a focus on minimizing the risk of stroke and other cardiovascular events.
• Patients should be actively involved in the decision-making process, with their preferences and values being taken into account when determining the best course of treatment.

From the Research

Treatment Options for Carotid Artery Stenosis

• Carotid endarterectomy (CEA) is a recommended treatment for symptomatic patients with moderate- to high-grade stenosis, as it has been shown to be effective in preventing ipsilateral ischemic events 2.
• Carotid artery stenting (CAS) is also a viable option for patients with carotid artery stenosis, although its safety and efficacy compared to CEA are still being debated 2.
• Medical therapy, including antiplatelet drugs, antihypertensive drugs, and lipid-lowering drugs, is the mainstay of treatment for asymptomatic patients with carotid artery stenosis, as well as for patients who are not candidates for surgical intervention 3, 4.

Individualized Management Strategies

• The management of patients with asymptomatic carotid stenosis may need to be individualized, taking into account factors such as patient age, comorbidities, and life expectancy 5.
• A multidisciplinary team approach is recommended for managing patients with carotid artery stenosis, including input from vascular surgeons, neurologists, and primary care physicians 3, 6.
• Lifestyle modifications, such as smoking cessation, diet, and exercise, are also important components of management strategies for patients with carotid artery stenosis 6.

Diagnostic and Imaging Modalities

• Duplex ultrasound (DUS) imaging is a widely preferred method for diagnosing carotid artery stenosis, due to its non-invasive nature and high sensitivity 6.
• Other imaging modalities, such as computed tomography angiography (CTA) and magnetic resonance angiography (MRA), may also be used to diagnose and evaluate the severity of carotid artery stenosis 3.

Current Debates and Ongoing Research

• The optimal management strategy for asymptomatic carotid stenosis is still a topic of debate, with some studies suggesting that medical therapy alone may be sufficient, while others recommend surgical intervention 3, 6.
• Ongoing research, such as the Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial (CREST-2), aims to provide more definitive guidelines for the management of asymptomatic carotid stenosis 3.