From the Guidelines
The initial treatment approach for cervical artery stenosis should involve medical management with antiplatelet therapy, specifically aspirin, as the clinical benefit of antithrombotic treatment in patients with asymptomatic cervical artery stenosis remains unproven, as shown in the 2024 ESC guidelines 1.
Medical Management
The medical management of cervical artery stenosis typically involves the use of antiplatelet therapy to prevent platelet aggregation and thrombus formation.
- Aspirin is the most commonly recommended antiplatelet agent, with a dose range of 81-325 mg daily.
- For patients who are contraindicated to aspirin, clopidogrel 75 mg daily may be considered as an alternative, as suggested by the 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline 1.
Risk Factor Modification
In addition to antiplatelet therapy, aggressive risk factor modification is essential to reduce the risk of morbidity and mortality associated with cervical artery stenosis.
- Smoking cessation is crucial, as smoking is a significant risk factor for the development and progression of atherosclerosis.
- Blood pressure control, with a target of less than 140/90 mmHg, is also important to reduce the risk of cardiovascular events.
- Diabetes management, with a target HbA1c of less than 7%, is necessary to prevent the progression of atherosclerosis.
- Cholesterol reduction with high-intensity statins, such as atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily, is recommended to achieve LDL levels below 70 mg/dL.
Lifestyle Modifications
Lifestyle modifications are also essential to reduce the risk of morbidity and mortality associated with cervical artery stenosis.
- Regular physical activity, such as walking or other aerobic exercises, can help to improve cardiovascular health.
- Weight management, with a goal of achieving a healthy body mass index, is important to reduce the risk of cardiovascular events.
- A Mediterranean or DASH diet, low in sodium and saturated fats, is recommended to reduce the risk of cardiovascular disease.
Interventional Approaches
For patients with symptomatic high-grade stenosis (>70%) or those who fail medical therapy, interventional approaches like carotid endarterectomy or stenting may be considered, but medical management remains the cornerstone of initial treatment for most patients with cervical artery stenosis.
From the Research
Initial Treatment Approach for Cervical Artery Stenosis
The initial treatment approach for cervical artery stenosis involves several options, including:
- Medical treatment
- Carotid endarterectomy (CEA)
- Percutaneous transluminal angioplasty (PTA) with/without stenting 2
- Antithrombotic therapy, such as antiplatelet therapy, to control the processes associated with atheroma and reduce the risk of embolic events 3
Treatment Options for Symptomatic and Asymptomatic Patients
For symptomatic patients, carotid endarterectomy (CEA) has been shown to be protective compared with medical therapy alone 4
- Stent angioplasty may be useful in the treatment of symptomatic cervical carotid stenosis in high-risk patients 4 For asymptomatic patients, there is little evidence that antiplatelet therapy is beneficial in preventing stroke or the progression of stenosis 3
- Aspirin (81-325 mg daily) is still reasonable to recommend for prevention of vascular events in asymptomatic patients 5
Perioperative Antithrombotic Therapy
Perioperative antithrombotic therapy should include aspirin for patients undergoing carotid endarterectomy, while the addition of clopidogrel should be decided case-by-case 3
- For patients undergoing carotid stenting, perioperative antithrombotic therapy should consist of a combination of aspirin plus clopidogrel 3
Recent Findings on Treatment Outcomes
Recent studies have investigated the clinical and procedural outcomes of management of cervical internal carotid artery (cICA) lesions, including the use of percutaneous transluminal angioplasty (PTA) or stent 6
- Acute carotid artery stenting (CAS) is effective for the management of cICA tandem lesions during mechanical thrombectomy, but care not to overextend may be important to reduce the risk of symptomatic intracranial hemorrhage (sICH) 6