From the Guidelines
Surgical intervention for internal carotid artery (ICA) stenosis is recommended when the stenosis reaches 70% or greater in symptomatic patients. This recommendation is based on the most recent and highest quality study, which suggests that carotid endarterectomy (CEA) is recommended for symptomatic patients with 70% to 99% ICA stenosis, provided the perioperative morbidity and mortality risk is estimated to be less than 6% 1.
Key Considerations
- The primary surgical options include CEA or carotid artery stenting (CAS), which aim to reduce the risk of future stroke by improving blood flow through the narrowed artery.
- The decision for intervention should be individualized based on the patient's overall health status, surgical risk factors, and life expectancy.
- Best medical therapy should be implemented regardless of surgical intervention and includes antiplatelet therapy, statin therapy to achieve LDL < 70 mg/dL, blood pressure control to target < 140/90 mmHg, and lifestyle modifications such as smoking cessation.
Specific Recommendations
- For symptomatic patients with 70% to 99% ICA stenosis, CEA is recommended if the perioperative morbidity and mortality risk is estimated to be less than 6% 1.
- For symptomatic patients with 50% to 69% ICA stenosis, CEA should be considered provided the perioperative morbidity and mortality risk is estimated to be less than 6% 1.
- Revascularization is not recommended in patients with ICA lesions less than 50% 1.
From the Research
Internal Carotid Artery Stenosis and Surgical Intervention
The decision to perform surgery on the Internal Carotid Artery (ICA) depends on the degree of stenosis and whether the patient is symptomatic or asymptomatic.
- For symptomatic patients, carotid endarterectomy is recommended for those with 70-99% stenosis 2, 3, 4.
- For asymptomatic patients, the recommendation for surgery varies, but it is generally considered for those with 80% or greater stenosis who are expected to live at least 5 years and are medically stable 5.
- The European Stroke Organisation guideline recommends carotid endarterectomy for patients with ≥60-99% asymptomatic carotid stenosis who are at increased risk of stroke on best medical treatment alone 2.
Degree of Stenosis and Treatment
The degree of stenosis is a critical factor in determining the need for surgical intervention.
- 50-69% stenosis: The benefit of carotid endarterectomy for symptomatic patients with this degree of stenosis is lower, with an absolute risk reduction of 4.6% at 5 years 3.
- 70-99% stenosis: Carotid endarterectomy is associated with an overall benefit for symptomatic patients with this degree of stenosis, with a risk ratio estimate of 0.67 for the combined end point of nonfatal stroke, nonfatal myocardial infarction, or death 4.
- ≥80% stenosis: Asymptomatic patients with this degree of stenosis may benefit from carotid endarterectomy if they are medically stable and expected to live at least 5 years 5.
Considerations for Surgical Intervention
Surgical intervention for ICA stenosis should be considered on a case-by-case basis, taking into account the patient's overall health, the degree of stenosis, and the presence of symptoms.
- The best medical therapy should accompany surgery in all situations 3.
- Carotid endarterectomy should be performed by experienced surgeons with low perioperative complication rates 5.
- The decision to perform surgery should be based on individual institutional experience and the patient's specific circumstances 3.