From the Guidelines
A patient with severe carotid stenosis should be referred to a multi-disciplinary Neuro-Vascular Team, which includes a neurologist/stroke specialist, a vascular surgeon, and an interventionalist, to determine the most appropriate treatment approach. This team-based approach is recommended by the most recent and highest quality study, published in 2025 1, which emphasizes the importance of a multi-disciplinary team in evaluating and managing patients with carotid stenosis. The team will assess the patient's suitability for surgery, stenting, or medical therapy, and discuss the viable treatment options with the patient, allowing for individualized and fully informed decision-making.
The referral should be made promptly, especially if the patient has experienced symptoms such as transient ischemic attacks or stroke, as intervention may prevent future cerebrovascular events. While awaiting specialist evaluation, the primary care physician should initiate medical therapy including antiplatelet medication, high-intensity statin therapy, and aggressive management of other cardiovascular risk factors, as recommended by previous studies 1. Severe carotid stenosis significantly increases stroke risk, and timely surgical intervention in appropriate candidates has been shown to reduce this risk substantially compared to medical therapy alone, particularly in symptomatic patients.
Some key points to consider when referring a patient with severe carotid stenosis include:
- The degree of stenosis, with severe stenosis typically defined as narrowing of 70% or greater
- The presence of symptoms, such as transient ischemic attacks or stroke
- The patient's overall health and medical history, including the presence of other cardiovascular risk factors
- The potential benefits and risks of surgical intervention, including carotid endarterectomy or carotid artery stenting, versus medical therapy alone.
By referring the patient to a multi-disciplinary Neuro-Vascular Team, the primary care physician can ensure that the patient receives comprehensive and individualized care, and that the most appropriate treatment approach is determined based on the patient's unique needs and circumstances.
From the Research
Specialty Referral for Severe Carotid Stenosis
The patient with severe carotid stenosis should be referred to a specialty that can provide the necessary interdisciplinary care.
- The optimum therapy for patients with carotid stenosis requires the cooperation of surgeons, neurologists, and angiologists 2.
- A vascular neurosurgeon or a neurologist can be the primary referral point, as they can assess the patient's condition and decide on the best course of treatment 3.
- The patient may also be referred to a cardiologist or a vascular surgeon, depending on the presence of other cardiovascular risk factors or the need for revascularization procedures such as carotid endarterectomy or carotid angioplasty and stenting 4, 5.
Treatment Options
The treatment of carotid stenosis depends on whether the stenosis is symptomatic or asymptomatic, and the patient's overall physical condition.
- For symptomatic carotid stenosis, the treatment options include intensive medical therapy, carotid endarterectomy, or carotid angioplasty and stenting 4, 5.
- Asymptomatic carotid stenosis may be managed with medical therapy alone, but revascularization procedures may be considered in certain cases 2, 5.
Importance of Timely Referral
Timely referral to a specialist is crucial in the management of carotid stenosis, as delays can increase the risk of stroke or other cardiovascular events.
- Current recommendations suggest that carotid endarterectomy should be performed within two weeks of symptom onset, but significant delays are common 6.
- Strategies to reduce these delays, such as streamlining the referral process and improving communication between healthcare providers, may be effective in increasing the proportion of procedures performed within the recommended timeframe 6.