At what percent occlusion do we perform carotid revascularization?

Carotid Revascularization Thresholds Based on Stenosis Percentage

Carotid revascularization is recommended for symptomatic patients with stenosis ≥50% and asymptomatic patients with stenosis ≥70%, while revascularization is not recommended for stenosis <50% in men and <70% in women. 1

Symptomatic Patients (with TIA or stroke within 6 months)

• Stenosis 70-99%: Strong recommendation for carotid revascularization (Class I recommendation) 1
• Stenosis 50-69%: Reasonable to consider revascularization, especially in men with symptoms within the last 6 months (Class IIa/IIb recommendation) 1
• Stenosis <50%: Revascularization is NOT recommended (Class III: No Benefit) 1

Asymptomatic Patients

• Stenosis 70-99%: Reasonable to perform revascularization if perioperative stroke/death risk is low (<3%) 1
• Stenosis 60-69%: May be considered in highly selected patients (minimum 60% by angiography, 70% by validated Doppler ultrasound) 1
• Stenosis <60%: Revascularization is NOT recommended 1

Special Considerations for Asymptomatic Patients

Revascularization may be considered in men with:

• Bilateral 70-99% carotid stenosis
• 70-99% carotid stenosis with contralateral occlusion
• 70-99% carotid stenosis with ipsilateral silent cerebral infarction 1

Revascularization is generally NOT recommended for:

• Women with asymptomatic stenosis (limited evidence of benefit)
• Patients with life expectancy <5 years
• Patients with chronic total occlusion of the targeted carotid artery 1

Procedural Considerations

Carotid Endarterectomy (CEA) vs. Carotid Artery Stenting (CAS)

• CEA is generally preferred for older patients and when arterial anatomy is unfavorable for endovascular intervention 1
• CAS may be preferred when neck anatomy is unfavorable for surgery (post-radiation, previous neck surgery, tracheostomy, etc.) 1

Timing of Intervention

• For symptomatic patients, intervention within 2 weeks of the index event is reasonable when there are no contraindications to early revascularization 1
• Perioperative risk must be <3% for asymptomatic patients and <6% for symptomatic patients to ensure benefit 1

Common Pitfalls to Avoid

1. Intervening on low-grade stenosis: Except in extraordinary circumstances, revascularization is not beneficial for stenosis <50% 1

2. Revascularizing chronic total occlusions: This is not recommended as it carries high risk with limited benefit 1, 2

3. Neglecting medical therapy: All patients should receive optimal medical therapy regardless of revascularization decision, including antiplatelet therapy, statins, and blood pressure control 1, 3

4. Failing to consider patient-specific factors: Age, comorbidities, life expectancy, and patient preferences should guide decision-making, especially for asymptomatic patients 1

5. Revascularizing patients with severe disability: Patients with severe disability from cerebral infarction that precludes preservation of useful function should generally not undergo revascularization 1

The decision to perform carotid revascularization requires careful consideration of stenosis severity, symptom status, surgical risk, and patient-specific factors to optimize outcomes in terms of stroke prevention and mortality reduction.