What is the recommended management for an 80% stenosis of the left internal carotid artery (ICA)?

From the Guidelines

For an 80% stenosis of the left internal carotid artery (ICA), carotid endarterectomy (CEA) is the recommended management, ideally performed within 14 days of symptom onset if the patient is symptomatic, as indicated by the 2024 ESC guidelines 1. This approach is based on the significant reduction in stroke risk associated with CEA for high-grade stenosis, particularly in symptomatic patients. The guidelines emphasize the importance of a documented 30-day risk of procedural death/stroke of less than 6% for recommending CEA for symptomatic 70%–99% ICA stenosis 1. Key considerations in the management of such patients include:

• The initiation of antiplatelet therapy, typically with aspirin, prior to and following the procedure, as supported by guidelines for the management of patients with peripheral arterial diseases 1.
• The use of statins, regardless of baseline cholesterol levels, with a preference for high-intensity statins, to reduce the risk of further vascular events, as recommended for patients with peripheral arterial diseases 1.
• Optimization of blood pressure to less than 140/90 mmHg and addressing other modifiable risk factors such as smoking, diabetes, and lifestyle modifications, in line with recommendations for the prevention of stroke in patients with stroke or transient ischemic attack 1. If CEA is contraindicated due to anatomical factors, comorbidities, or high surgical risk, carotid artery stenting (CAS) may be considered as an alternative, particularly for symptomatic patients at average or low risk of complications associated with endovascular intervention, as suggested by guidelines for the prevention of stroke 1. The choice between CEA and CAS should be individualized based on patient-specific factors, including age, comorbidities, and the presence of contraindications to either procedure. Ultimately, the decision for revascularization should be made by a multidisciplinary team, considering the patient's overall risk profile and potential benefits of the intervention, in accordance with the principles outlined in the guidelines for the management of peripheral arterial and aortic diseases 1.

From the Research

Management of 80% Left Internal Carotid Artery Stenosis

The management of an 80% stenosis of the left internal carotid artery (ICA) involves a combination of medical therapy and potential revascularization procedures.

• Medical Therapy: The cornerstone of management for patients with carotid artery stenosis, whether asymptomatic or symptomatic, 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.
  • Pharmacological components including blood pressure and diabetes control, antiplatelet agents (e.g., aspirin), and lipid-lowering treatment with statins/ezetimibe.
• Antiplatelet Therapy: Antiplatelet therapy is recommended for patients with a history of ischemic stroke and/or significant carotid artery stenosis. Aspirin and clopidogrel are the most widely used agents 3. For asymptomatic carotid stenosis, aspirin (81-325 mg daily) is reasonable for the prevention of vascular events 4.
• Revascularization: The decision for revascularization (carotid endarterectomy or stenting) depends on the presence of symptoms, the degree of stenosis, and the patient's overall risk profile. Intensive medical therapy has been shown to be highly effective, potentially reducing the need for revascularization in many patients 5.
• Risk Factor Management: Management of modifiable risk factors such as hypertension, hyperlipidemia, diabetes, and smoking is crucial to reduce the risk of stroke and progression of carotid artery stenosis 6.

Considerations for Asymptomatic vs. Symptomatic Patients

• Asymptomatic Patients: The use of antiplatelet therapy in asymptomatic patients is less clear, with some evidence suggesting a benefit but also acknowledging the risk of bleeding complications 4.
• Symptomatic Patients: For symptomatic patients, especially those with a recent transient ischemic attack or stroke, combination antiplatelet therapy with aspirin and clopidogrel may be considered to reduce the risk of recurrent stroke 5, 6.

Ongoing Research and Guidelines

Ongoing trials are comparing the risks and benefits of carotid revascularization versus intensive medical therapy alone 5, aiming to provide clearer guidelines for the management of carotid artery stenosis.