From the Guidelines
Carotid endarterectomy (CEA) is the preferred treatment for symptomatic patients with >50% stenosis, and should be performed within 2 weeks of symptom onset, as it has been shown to significantly reduce the risk of stroke and death 1. The management of carotid artery stenosis depends on the degree of stenosis, symptoms, and patient risk factors.
Medical Management
For asymptomatic patients with less than 60% stenosis, medical management is recommended, including:
- Antiplatelet therapy (aspirin 81-325 mg daily or clopidogrel 75 mg daily)
- High-intensity statin therapy (atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily)
- Blood pressure control (target <140/90 mmHg)
- Smoking cessation
- Diabetes management
Carotid Revascularization
For symptomatic patients with >50% stenosis or asymptomatic patients with >60-70% stenosis, carotid revascularization should be considered in addition to medical therapy.
- Carotid endarterectomy (CEA) is generally preferred for most patients with suitable anatomy and low surgical risk
- Carotid artery stenting (CAS) may be appropriate for patients with high surgical risk, previous neck radiation, prior neck surgery, or contralateral laryngeal nerve palsy The timing of intervention for symptomatic patients is crucial, with optimal benefit when performed within 2 weeks of symptom onset, as recommended by the Canadian Stroke Best Practice Recommendations 1. Regular follow-up with carotid ultrasound is recommended every 6-12 months for patients with moderate stenosis managed medically. These interventions aim to reduce stroke risk by improving blood flow through the carotid artery and preventing plaque rupture and embolization, which are the primary mechanisms of stroke in carotid stenosis. According to the European Society of Cardiology guidelines, all patients with symptomatic carotid stenosis should receive long-term antiplatelet therapy and statin therapy, and CEA should be considered as long as the perioperative stroke and death rate for procedures performed by the surgical team is <3% and the patient’s life expectancy exceeds 5 years 1. The most recent and highest quality study, the Canadian Stroke Best Practice Recommendations, sixth edition practice guidelines, update 2017, provides the best evidence for the management of carotid artery stenosis 1.
From the Research
Management of Carotid Artery Stenosis
The management of carotid artery stenosis involves a combination of medical and surgical therapies to reduce the risk of stroke and vascular events. The following are some key aspects of management:
- Medical management:
- Optimal management of carotid artery stenosis requires the use of medications or lifestyle modifications to control the processes associated with atheroma and reduce the risk of embolic events 2.
- Antiplatelet therapy should be considered, particularly in symptomatic patients with carotid atherosclerosis 2.
- Surgical management:
- Carotid endarterectomy (CEA) is a recommended intervention for symptomatic carotid artery stenosis, with the goal of reducing the risk of perioperative stroke and death 3, 4, 5.
- Transcarotid revascularization may also have similar outcomes to CEA 3.
- Carotid artery stenting (CAS) is another less invasive surgical option that has similar outcomes to CEA over the long-term 6, 4.
Timing of Intervention
The timing of intervention is crucial in the management of symptomatic carotid artery stenosis:
- The risk of perioperative stroke and death is higher during the hyperacute period within 48 hours, while the risk of recurrent stroke increases if intervention is delayed beyond 14 days 3.
- The ideal timing of intervention must balance these risks, taking into account factors such as acuity of neurologic deficit, degree of stenosis, and comorbidities 3.
Asymptomatic Carotid Artery Stenosis
The management of asymptomatic carotid artery stenosis is more controversial:
- Medical management alone is advocated for patients with asymptomatic carotid stenosis, with the goal of reducing the risk of stroke through control of risk factors and use of antithrombotic agents 2, 6, 4.
- CEA and CAS are also options for asymptomatic patients, particularly those with severe stenosis, but the decision to intervene must be individualized based on patient risk factors and comorbidities 6, 4.