What is the recommended treatment for left internal carotid artery (ICA) stenosis due to atherosclerosis?

From the Guidelines

The recommended treatment for left internal carotid artery (ICA) stenosis due to atherosclerosis is carotid endarterectomy (CEA) for symptomatic patients with 70%–99% stenosis, provided a documented 30-day risk of procedural death/stroke is <6% 1. When considering treatment options, the severity of stenosis and symptoms are crucial factors.

• For asymptomatic patients with less than 50% stenosis, medical therapy is typically recommended, including antiplatelet medications, high-intensity statin therapy, blood pressure control, and lifestyle modifications.
• For symptomatic patients with stenosis ≥50% or asymptomatic patients with stenosis ≥70%, carotid revascularization should be considered in addition to medical therapy. Some key points to consider:
• CEA is generally preferred for most patients, while carotid artery stenting (CAS) may be appropriate for those with high surgical risk, previous neck radiation, or prior neck surgery 1.
• The decision between CEA and CAS should be individualized based on patient factors and surgical risk.
• Revascularization procedures are most beneficial when performed within 2 weeks of symptom onset for symptomatic patients, as recommended by the 2024 ESC guidelines for the management of peripheral arterial and aortic diseases 1. These interventions reduce stroke risk by removing or bypassing the atherosclerotic plaque that can either restrict blood flow or serve as a source of emboli to the brain. It is essential to note that the 2024 ESC guidelines provide the most recent and highest quality evidence for the management of carotid artery stenosis, and therefore, their recommendations should be prioritized in clinical practice 1.

From the Research

Treatment Options for Left Internal Carotid Artery (ICA) Stenosis

The treatment for left ICA stenosis due to atherosclerosis depends on the severity of the stenosis and the presence of symptoms.

• For symptomatic patients with stenosis of 70-99%, carotid endarterectomy (CEA) is recommended 2, 3, 4.
• For asymptomatic patients with stenosis of 60-99%, CEA may be considered, especially if they are at increased risk of stroke on best medical treatment alone 3.
• Carotid artery stenting (CAS) may be considered in patients < 70 years old with symptomatic stenosis of 50-99% 3, 5.
• Antiplatelet therapy should be considered in all patients with carotid stenosis, especially in symptomatic patients for secondary prevention of recurrent stroke 6.

Considerations for Treatment

When deciding on treatment, several factors should be considered, including:

• The degree of stenosis
• The presence of symptoms
• The patient's medical condition and age
• The risk of surgical complications
• The presence of other cerebral arterial stenoses or occlusions
• The patient's lifestyle and ability to adhere to medical treatment

Surgical and Endovascular Treatment

Both CEA and CAS have been shown to be effective in reducing the risk of stroke in patients with carotid stenosis.

• CEA is generally recommended for patients with symptomatic stenosis of 70-99% and asymptomatic stenosis of 60-99% 2, 3, 4.
• CAS may be considered in patients < 70 years old with symptomatic stenosis of 50-99% and in patients who are at high risk for surgical complications 3, 5.