What is the next best step in managing a 64-year-old man with hyperlipidemia and a 75% blockage of the left common carotid artery, who is on daily aspirin and atorvastatin, following a recent transient ischemic attack?

Management of Symptomatic Carotid Artery Stenosis

Carotid endarterectomy (CEA) is the next best step in management for this 64-year-old man with symptomatic high-grade (75%) carotid stenosis following a recent TIA. 1

Rationale for Recommending CEA

Patient-Specific Factors Supporting CEA

• 75% blockage of left common carotid artery (symptomatic high-grade stenosis)
• Recent transient ischemic attack (symptomatic status)
• Surgically accessible carotid plaque
• Low perioperative risk (<6% morbidity and mortality)
• Already on appropriate medical therapy (aspirin and atorvastatin)

Evidence-Based Recommendation

The American Heart Association/American College of Cardiology Foundation guidelines strongly recommend CEA for patients with:

• Symptomatic carotid stenosis >70% by noninvasive imaging or >50% by catheter angiography 1
• Recent TIA or non-disabling stroke within 6 months 1
• Low perioperative risk (<6% combined stroke/mortality) 1

Timing of Intervention

• When revascularization is indicated for patients with TIA and no contraindications exist, intervention within 2 weeks of the index event is reasonable rather than delaying surgery 1
• Early intervention reduces the risk of recurrent stroke in the vulnerable period following a TIA

Alternative Considerations

Carotid Artery Stenting (CAS)

• CAS is indicated as an alternative to CEA for symptomatic patients at average or low risk when carotid stenosis is >70% 1
• However, CEA is preferred over CAS in older patients, particularly when arterial anatomy is not specified as unfavorable for surgical intervention 1
• The guidelines state: "It is reasonable to choose CEA over CAS when revascularization is indicated in older patients" 1

Medical Therapy Alone

• Not sufficient as the sole treatment for symptomatic high-grade stenosis
• This patient is already on appropriate medical therapy (aspirin and atorvastatin)
• Medical therapy alone would leave the patient at significant risk for recurrent stroke

Perioperative Management

Before CEA

• Continue aspirin therapy (75-325 mg daily) 1
• Continue statin therapy 1
• Control blood pressure before and after CEA 1

After CEA

• Long-term antiplatelet therapy with aspirin (75-325 mg daily), clopidogrel (75 mg daily), or combination of low-dose aspirin plus extended-release dipyridamole 1
• Continue statin therapy regardless of lipid levels 1

Follow-up Recommendations

• Non-invasive imaging of extracranial carotid arteries at 1 month, 6 months, and annually after CEA 1
• Once stability is established, surveillance intervals may be extended
• Monitor for development of restenosis or contralateral lesions

Common Pitfalls to Avoid

• Delaying intervention beyond 2 weeks after TIA increases risk of recurrent stroke
• Discontinuing antiplatelet therapy before CEA increases perioperative stroke risk
• Failing to optimize blood pressure control increases perioperative complications
• Neglecting long-term surveillance for restenosis or progression of contralateral disease

By proceeding with CEA in this symptomatic patient with high-grade stenosis and low surgical risk, you will significantly reduce his risk of future stroke and optimize his long-term outcomes.