From the Guidelines
Surgical intervention is warranted for carotid stenosis when the narrowing reaches 70% or greater in symptomatic patients who have experienced a stroke or transient ischemic attack (TIA) 1.
Key Considerations
- The decision to intervene should be individualized based on surgical risk, life expectancy, and comorbidities.
- The procedure of choice is carotid endarterectomy (CEA), which involves removing the plaque from the artery to restore normal blood flow.
- For patients who are poor surgical candidates, carotid artery stenting (CAS) may be an alternative.
Recommendations
- CEA is recommended for symptomatic 70%–99% ICA stenosis provided a documented 30-day risk of procedural death/stroke is <6% 1.
- CEA should be performed within 14 days in symptomatic ICA stenosis patients if possible 1.
- CAS may be considered for symptomatic patients at high risk for CEA with a 70%–99% ICA stenosis, provided a documented 30-day risk of procedural death/stroke is <6% 1.
Medical Management
- Medical management with antiplatelet therapy, statins, blood pressure control, and lifestyle modifications should be implemented regardless of whether surgical intervention is pursued.
- Optimal medical therapy is recommended for all patients with carotid artery stenosis and a TIA or stroke 1.
Important Notes
- Revascularization is not recommended in patients with ICA lesions <50% 1.
- The benefit of surgery is greatest when performed within two weeks of symptom onset for symptomatic patients.
From the Research
Degree of Carotid Stenosis for Surgical Intervention
The degree of carotid stenosis at which surgical intervention is warranted can be summarized as follows:
- For symptomatic patients, carotid endarterectomy is indicated for carotid artery stenosis of 70 to 99 percent 2, 3, 4, 5, 6.
- For symptomatic patients with carotid artery stenosis of 50 to 69 percent, carotid endarterectomy may provide modest benefit, especially if the patient has a low surgical risk 2, 4, 5.
- For asymptomatic patients, carotid endarterectomy may be beneficial for those with carotid artery stenosis of 60 percent or greater, especially if they are good candidates for elective surgery and the arteriographic and surgical complication rates are low 2, 3, 4, 5, 6.
Key Considerations
Some key considerations for surgical intervention include:
- The patient's overall health and surgical risk 2, 3, 4, 5, 6.
- The presence of symptoms, such as transient ischemic attacks or minor strokes 2, 3, 4, 5, 6.
- The degree of carotid stenosis, with higher degrees of stenosis generally indicating a greater benefit from surgical intervention 2, 3, 4, 5, 6.
- The use of best medical therapy, including antiplatelet agents, statins, and lifestyle modifications, which may be recommended for patients with less severe carotid stenosis or those who are not good candidates for surgery 2, 3, 4, 5.