What is the management approach for a patient with 75% Internal Carotid Artery (ICA) stenosis?

Management of 75% Internal Carotid Artery Stenosis

For patients with symptomatic 75% ICA stenosis, carotid endarterectomy (CEA) is recommended within 14 days of symptom onset, provided the perioperative stroke/death risk is <6%. 1

Initial Assessment and Classification

• First determine if the stenosis is symptomatic or asymptomatic:

  • Symptomatic: Recent (<6 months) TIA or stroke in the territory of the stenosed carotid
  • Asymptomatic: No recent neurological symptoms attributable to the stenosis

• Confirm stenosis severity using:

  • Duplex ultrasound (DUS) as first-line imaging 1
  • Use NASCET method or equivalent for assessment (not ECST method) 1

Management Algorithm

For Symptomatic 75% ICA Stenosis:

1. Urgent Revascularization:

   • CEA within 14 days of symptom onset (Class I, Level B recommendation) 1
   • Ensure documented 30-day procedural stroke/death risk is <6% 1

2. Optimal Medical Therapy (OMT) - must be provided regardless of revascularization:

   • Dual antiplatelet therapy (DAPT):
     • Aspirin (75-325 mg) plus clopidogrel (75 mg) for first 21 days 1, 2
     • Then monotherapy with clopidogrel 75 mg or aspirin long-term 1
   • High-intensity statin therapy:
     • Target >50% LDL-C reduction
     • Goal LDL-C <55 mg/dL 2
   • Blood pressure control (<140/90 mmHg) 2
   • Lifestyle modifications (smoking cessation, Mediterranean diet, regular exercise) 2

3. Post-Revascularization Follow-up:

   • DUS surveillance within first month after procedure 1
   • Annual follow-up to check for cardiovascular risk factors and treatment compliance 1
   • Regular assessment of neurological symptoms 1

For Asymptomatic 75% ICA Stenosis:

1. Risk Stratification:

   • Assess life expectancy (revascularization not recommended if <5 years) 1
   • Evaluate for high-risk features (rapid progression, silent emboli, etc.)

2. Management Options:

   • For men <75 years with good life expectancy (≥5 years):
     • Consider CEA if perioperative stroke/death risk is <3% 3
   • For women:
     • Benefits from CEA are significantly less than in men 3
     • Consider CEA only in younger, fit women 3
   • For all patients:
     • Implement comprehensive OMT as described above

Important Considerations and Pitfalls

• Timing is critical: For symptomatic patients, early intervention (within 14 days) provides maximum benefit for stroke prevention 1

• Procedural selection: CEA is generally preferred over carotid artery stenting (CAS) unless patient has high surgical risk factors 4

• Medical therapy is not sufficient alone for symptomatic severe stenosis: A study showed 24.6% of medically managed patients with severe stenosis developed ipsilateral neurological symptoms during follow-up, with most (74%) occurring within 12 months 5

• Very severe stenosis (90-99%) carries higher risk: These patients have 3.23 times higher risk of ipsilateral neurological symptoms compared to 70-89% stenosis 5

• Avoid undertreatment: Failure to prescribe appropriate antiplatelet and statin therapy misses an opportunity for stroke prevention 2

• Regular surveillance is essential: Annual DUS monitoring helps detect progression of stenosis 2