From the Guidelines
The next step in managing a patient with high-grade focal stenosis at bilateral external carotid arteries is typically conservative management, as these lesions rarely require intervention. Medical therapy should be initiated with antiplatelet medication (aspirin 81-325 mg daily or clopidogrel 75 mg daily), along with aggressive risk factor modification including statin therapy (such as atorvastatin 40-80 mg daily), blood pressure control (target <140/90 mmHg), smoking cessation, and diabetes management if applicable 1. Unlike internal carotid artery stenosis, external carotid artery stenosis generally doesn't cause stroke and has extensive collateral circulation, making surgical or endovascular interventions unnecessary in most cases.
Some key points to consider in the management of these patients include:
- Smoking cessation is recommended in all patients with peripheral arterial diseases, including those with external carotid artery stenosis 1
- Statins are recommended in all patients with peripheral arterial diseases to reduce LDL-C to < 1.8 mmol/L (70 mg/dL) or decrease it by > 50% if baseline values are 1.8–3.5 mmol/L (70–135 mg/dL) 1
- Antiplatelet therapy is recommended in patients with symptomatic peripheral arterial diseases, but its use in asymptomatic external carotid artery stenosis is not well established 1
- Blood pressure control is essential, with a target of < 140/90 mmHg 1
Patients should be monitored with periodic carotid ultrasound every 6-12 months to assess for progression. Intervention would only be considered in rare circumstances where patients have severe symptoms directly attributable to external carotid stenosis, such as facial ischemia or jaw claudication that significantly impacts quality of life. The focus remains on preventing atherosclerotic progression through comprehensive medical management rather than procedural intervention.
From the Research
Management of High-Grade Focal Stenosis at Bilateral External Carotid Arteries
The management of high-grade focal stenosis at bilateral external carotid arteries involves a comprehensive approach that includes both medical therapy and potential invasive procedures.
- Medical Therapy: The cornerstone of management for patients with carotid artery stenosis, including those with bilateral external carotid arteries stenosis, is the implementation of best medical treatment (BMT) 2. This includes lifestyle modifications such as smoking cessation, maintaining a healthy body weight, moderate exercise, and a Mediterranean diet. Additionally, pharmacological components of BMT comprise blood pressure and diabetes control, antiplatelet agents, and lipid-lowering treatment with statins/ezetimibe 2, 3.
- Invasive Procedures: For symptomatic patients with high-grade carotid stenosis, revascularization procedures such as carotid endarterectomy (CEA) or carotid artery stenting (CAS) are considered 4, 3. The choice between CEA and CAS may be influenced by anatomy, prior illness or treatment, or patient risk 3. In cases of bilateral carotid stenosis, a combined treatment strategy using both CEA and CAS may be favorable to minimize surgical risks 5.
- Evaluation and Risk Assessment: The evaluation of carotid stenosis should be performed by ultrasound as a first-line examination, complemented by computed tomography angiography (CTA) and/or magnetic resonance angiography to assess the extent and severity of extracranial carotid stenosis 3. The decision for revascularization should consider the degree of stenosis, symptoms, and the patient's overall risk profile 3.
- Specific Considerations for Bilateral External Carotid Arteries Stenosis: While the provided studies primarily focus on internal carotid artery stenosis, the principles of medical management and risk factor modification are applicable to external carotid artery stenosis as well. However, the decision for invasive procedures in bilateral external carotid arteries stenosis may require individualized assessment considering the specific anatomy and clinical context.