What is the treatment for carotid stenosis?

Treatment of Carotid Stenosis

The treatment of carotid stenosis should be stratified based on symptom status and degree of stenosis, with carotid endarterectomy (CEA) recommended for symptomatic patients with 70-99% stenosis within 14 days of symptom onset, while asymptomatic patients should receive aggressive medical management as first-line therapy. 1

Treatment Algorithm Based on Symptom Status

For Symptomatic Carotid Stenosis:

1. Degree of Stenosis Assessment:

   • Use NASCET method or equivalent non-invasive method 1
   • Duplex ultrasound as first-line imaging 1
   • CTA or MRA for equivocal cases or pre-intervention planning 1

2. Treatment by Stenosis Severity:

   • 70-99% stenosis: CEA is strongly recommended (within 14 days of symptoms) 1
   • 50-69% stenosis: CEA may be considered, especially in men, patients >75 years, and those with recent symptoms 1
   • <50% stenosis: Revascularization is NOT recommended 1

3. Timing of Intervention:

   • Ideally within 14 days of symptom onset 1
   • For stable patients, within the first days following TIA/minor stroke 1
   • Caution with very early (<48h) intervention in patients with large infarcts or impaired consciousness 1

4. Antithrombotic Therapy:

   • If not revascularized: DAPT (aspirin plus clopidogrel) for at least 21 days, then single antiplatelet therapy 1
   • After CEA: Long-term aspirin or clopidogrel 1
   • After stenting: DAPT for at least 1 month, then long-term single antiplatelet therapy 1

For Asymptomatic Carotid Stenosis:

1. First-line Treatment:

   • Aggressive medical management of risk factors 1, 2
   • Antiplatelet therapy 3
   • Blood pressure control (target <140/90 mmHg) 1, 3
   • Intensive lipid-lowering therapy (statin to reduce LDL <70 mg/dL) 1
   • Lifestyle modifications (smoking cessation, diet, exercise) 1, 4

2. Consider Revascularization Only If:

   • 60-99% stenosis AND 1
   • Life expectancy >5 years AND 1
   • Low surgical risk (<3% perioperative morbidity/mortality) 1
   • High-risk features present (ulceration, intraplaque hemorrhage, embolus detection, progression) 2

3. Revascularization Method:

   • CEA preferred for patients >70 years 1
   • CAS for patients with technical/anatomical contraindications to surgery 1

Medical Management Components

1. Antiplatelet Therapy:

   • Single antiplatelet therapy for asymptomatic patients 3
   • DAPT for symptomatic patients (for at least 21 days) 1

2. Lipid Management:

   • Statin therapy to reduce LDL <100 mg/dL for all patients 1
   • Target LDL <70 mg/dL for patients with prior stroke 1
   • Consider adding other lipid-lowering agents if statin alone insufficient 1

3. Blood Pressure Control:

   • Target <140/90 mmHg 1
   • Blood pressure control is independently associated with reduced stroke risk 3

4. Other Risk Factor Management:

   • Smoking cessation 1
   • Diabetes management (though intensive glucose control benefit not established) 1
   • Lifestyle modifications 4

Follow-up Recommendations

1. After Revascularization:

   • DUS within the first month 1
   • Annual follow-up to check CVRFs and treatment compliance 1
   • Assessment of neurological symptoms at least yearly 1

2. For Medically Managed Patients:

   • Annual assessment of degree of stenosis 1
   • Monitor for progression (≥2 stenosis categories in 1 year indicates high risk) 1
   • Regular assessment of treatment adherence 1

Important Caveats

• Recent evidence suggests annual stroke risk with modern medical therapy for asymptomatic stenosis has fallen to ≤1% 1, 2
• The benefit of CEA may be reduced or eliminated with current optimal medical therapy 1
• Perioperative stroke/death risk should be <3% for asymptomatic patients and <6% for symptomatic patients 1
• Revascularization should be performed by experienced centers with documented low complication rates 1
• The benefit of revascularization in asymptomatic women remains controversial 1
• Multidisciplinary assessment (Neuro-Vascular Team) is recommended for treatment decisions 1

The treatment landscape for carotid stenosis continues to evolve, with ongoing trials comparing modern medical therapy to revascularization. Current evidence suggests a more selective approach to revascularization, especially in asymptomatic patients, with emphasis on optimal medical therapy for all patients regardless of intervention status.