What is the treatment for carotid calcification?

Treatment of Carotid Calcification

The treatment of carotid calcification requires a comprehensive approach including optimal medical therapy as the foundation, with carotid revascularization (endarterectomy or stenting) considered for patients with significant stenosis or high-risk features. 1

Risk Assessment and Diagnosis

• Carotid atherosclerotic disease (CarAD) with calcification is an important cause of stroke, accounting for approximately 18-25% of ischemic strokes 2
• Calcified carotid plaques are more common in males and occur more frequently in the carotid than coronary arteries 1
• The most common locations for calcified deposits are the carotid bulb (76%), particularly on the lateral wall opposite the flow divider, and the proximal internal carotid artery (55%) 3
• Diagnostic imaging modalities include:
  • Computed tomography angiography (CTA) - confirmatory test that enables examination of plaque composition and calculation of carotid calcification score 4
  • Magnetic resonance angiography (MRA), duplex ultrasound, PET-CT, and optical coherence tomography 4

Medical Management

Lifestyle Modifications

• Lifestyle measures are essential for reducing stroke risk and overall cardiovascular risk 1
• Key interventions include:
  • Smoking cessation
  • Weight loss
  • Regular exercise
  • Balanced diet with increased consumption of vegetables, fruits, and soy protein 1
  • Reduced intake of meat, poultry, and eggs 1

Pharmacological Management

1. Lipid-lowering therapy:

   • Intensive statin therapy is the cornerstone of treatment 1
   • Target LDL-C < 55 mg/dL 1
   • Consider ezetimibe or PCSK9 inhibitors as alternatives or adjunctive therapies 1
   • Evolocumab has been shown to reduce ischemic stroke risk (HR 0.75,95% CI 0.62-0.92) 1

2. Antithrombotic therapy:

   • Single antiplatelet therapy for asymptomatic carotid stenosis 1
   • For symptomatic patients, ticagrelor has shown superiority to aspirin in preventing stroke, MI, or death (HR 0.68,95% CI 0.53-0.88) 1
   • After carotid revascularization:
     • Post-CEA: Single antiplatelet therapy for 1-3 months 1
     • Post-CAS: Dual antiplatelet therapy for 1-3 months, followed by single antiplatelet therapy 1

3. Antihypertensive therapy:

   • Blood pressure control is essential for all patients with carotid calcification 1

Revascularization Options

Indications for Revascularization

• Revascularization should be considered for:
  • Symptomatic patients with high-grade stenosis and recent stroke/TIA 1
  • Asymptomatic patients with significant stenosis and increased-risk morphology or embolic signals 1
  • Patients with prior TIA 1

Carotid Endarterectomy (CEA)

• Traditional surgical approach for removing calcified plaque 4
• Periprocedural combined rate of stroke or death should not exceed 2% for asymptomatic stenoses and 4% for symptomatic stenoses 1
• Lower risk of procedural stroke compared to CAS, but higher risk of perioperative MI 1

Carotid Artery Stenting (CAS)

• Less invasive alternative to CEA 1
• May be preferred for patients with high surgical risk 4
• For severely calcified lesions, intravascular lithotripsy (IVL) has shown promise as an adjunct to CAS 5
• Modern stenting techniques include:
  • Embolic protection devices to reduce procedural stroke risk 5
  • Mesh stents for increased plaque coverage 1

Special Considerations

• Calcified carotid plaque is associated with more severe coronary artery disease 1
• Severe carotid siphon calcification is independently associated with unfavorable outcomes (adjusted OR 4.06,95% CI 1.98-8.33) and early cerebral ischemia 6
• Daily aspirin intake may mitigate the negative impact of severe carotid siphon calcification on outcomes 6
• No significant difference in degree of calcification between patients with and without diabetes 3
• Women tend to develop carotid calcification at an older age compared to men 3

Treatment Algorithm

1. For patients with <50% stenosis without prior stroke:

   • Optimize medical therapy and monitor 1
   • Address cardiovascular risk factors and lifestyle modifications 1

2. For patients with significant stenosis but no prior stroke/TIA and low-risk morphology:

   • Optimize medical therapy and monitor, considering patient-specific factors 1
   • Regular follow-up imaging to assess progression 1

3. For patients with significant stenosis and prior TIA or increased-risk morphology:

   • Consider revascularization (CEA or CAS) based on patient characteristics 1
   • Continue optimal medical therapy 1

4. For patients with high-grade stenosis and recent stroke/TIA:

   • Revascularization is beneficial 1
   • Choose between CEA and CAS based on:
     • Patient age (CAS may have higher procedural risk in older patients) 1
     • Anatomical considerations 1
     • Surgical risk factors 1
     • Degree of calcification (severe calcification may favor IVL-assisted CAS) 5