What are the treatment indications for carotid artery stenosis?

From the Guidelines

Treatment for carotid artery stenosis should be guided by the degree of stenosis and symptom status, with carotid endarterectomy (CEA) or carotid artery stenting (CAS) recommended for symptomatic patients with stenosis ≥50% or asymptomatic patients with stenosis ≥60-70%, as stated in the 2024 ESC guidelines 1.

Key Considerations

• The timing of intervention for symptomatic patients is crucial, with surgery ideally performed within 2 weeks of symptom onset to maximize stroke prevention benefits, as recommended by the 2024 ESC guidelines 1.
• The choice between CEA and CAS depends on patient-specific factors including age, anatomical considerations, comorbidities, and surgical risk, as noted in the 2011 American Heart Association/American Stroke Association guidelines 1.
• All patients, regardless of intervention, should receive optimal medical therapy including antiplatelet agents, high-intensity statin therapy, blood pressure control, diabetes management, smoking cessation, and lifestyle modifications, as emphasized in the 2025 clinical consensus statement of the ESC Council on Stroke and the ESC Working Group on Aorta and Peripheral Vascular Diseases 1.

Medical Therapy

• 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 artery disease, as recommended in the 2025 clinical consensus statement 1.
• Combination therapy with clopidogrel and aspirin may be more effective than aspirin alone in reducing asymptomatic embolization, as suggested by the Acute Stroke or Transient Ischaemic Attack Treated with Aspirin or Ticagrelor and Patient Outcomes trial, cited in the 2025 clinical consensus statement 1.

Asymptomatic Carotid Stenosis

• For asymptomatic patients with carotid stenosis, medical therapy alone is typically sufficient for those with mild to moderate stenosis (<60%), as noted in the 2014 American Heart Association/American Stroke Association guidelines 1.
• Revascularization may be considered for asymptomatic patients with high-risk features and a life expectancy >5 years, as stated in the 2024 ESC guidelines 1.

From the Research

Treatment Indications for Carotid Artery Stenosis

The treatment indications for carotid artery stenosis can be summarized as follows:

• For symptomatic patients, carotid endarterectomy (CEA) or carotid artery stenting (CAS) is recommended if stenosis is greater than 50% 2, 3.
• For asymptomatic patients, CEA or CAS may be considered if stenosis is greater than 60% and the patient has a high risk of stroke 4, 2.
• Medical management, including antiplatelet therapy, antihypertensive drugs, and lipid-lowering drugs, is recommended for all patients with carotid stenosis 5, 6.
• The decision to perform CEA or CAS should be based on individual patient characteristics, including anatomy, prior illness or treatment, and patient risk 2, 3.

Factors to Consider in Treatment Decision

Several factors should be considered when deciding on the treatment for carotid artery stenosis, including:

• Severity of stenosis 2
• Presence of symptoms 2, 3
• Patient's overall health and risk factors 4, 6
• Anatomy of the carotid artery 2, 3
• Prior illness or treatment 2, 3
• Patient's preferences and values 4, 6

Medical Management

Medical management of carotid artery stenosis includes:

• Antiplatelet therapy 5, 6
• Antihypertensive drugs 6
• Lipid-lowering drugs 6
• Lifestyle modifications, such as stopping smoking and monitoring hypertension, hyperlipidemia, and diabetes 5