What is the best treatment for a patient with severe Internal Carotid Artery (ICA) stenosis and a 11mm fusiform aneurysm?

Management of Severe ICA Stenosis with 11mm Fusiform Aneurysm

For patients with severe internal carotid artery (ICA) stenosis and a fusiform aneurysm of 11mm, surgical intervention with carotid endarterectomy (CEA) is recommended as the first-line treatment to prevent stroke and aneurysm-related complications.

Assessment and Diagnostic Approach

• Duplex ultrasound (DUS) should be used as the first-line imaging modality to confirm the degree of ICA stenosis 1
• The NASCET method or its non-invasive equivalent should be used to accurately quantify the degree of stenosis 1
• Additional imaging with CT angiography (CTA) or MR angiography (MRA) is necessary to fully characterize the fusiform aneurysm and plan appropriate intervention 1
• Assessment by a multidisciplinary vascular team including a neurologist is essential to determine the optimal management strategy 1

Treatment Algorithm

For Symptomatic Patients (with recent stroke/TIA):

• CEA is strongly recommended for symptomatic 70%-99% ICA stenosis with a documented 30-day procedural risk of death/stroke <6% 1
• The procedure should be performed within 14 days of symptom onset to maximize benefit 1
• For the fusiform aneurysm component, surgical reconstruction during CEA is preferred over endovascular approaches due to the aneurysm size (11mm) and morphology (fusiform) 2, 3
• If CEA is contraindicated due to anatomical factors (such as lesions extending above C2 vertebra), endovascular treatment with stenting may be considered 4

For Asymptomatic Patients:

• CEA should still be considered due to the presence of both severe stenosis and a sizeable fusiform aneurysm, which represents a high-risk combination 2, 5
• The presence of the aneurysm increases rupture risk and potential for thromboembolic complications, warranting intervention even in asymptomatic cases 2
• Patients with anatomic factors making CEA difficult (high lesions, previous neck surgery) may be considered for carotid artery stenting (CAS) or transcarotid artery revascularization (TCAR) 4

Perioperative Management

• Dual antiplatelet therapy (DAPT) with low-dose aspirin and clopidogrel (75 mg) should be initiated before intervention 1
• For patients undergoing CEA, antiplatelet therapy should be continued perioperatively to reduce thromboembolic risk 1
• For patients receiving stents, DAPT should be continued for at least 1 month post-procedure 1

Post-Intervention Management

• After CEA or stenting, surveillance with DUS is recommended within the first month 1
• Long-term aspirin or clopidogrel should be continued indefinitely after revascularization 1
• Annual follow-up is recommended to assess neurological symptoms, cardiovascular risk factors, and treatment adherence 1, 6
• Optimal medical therapy including statins, blood pressure control, and management of other cardiovascular risk factors should be implemented 1, 6

Important Considerations and Pitfalls

• The combination of severe stenosis and a sizeable fusiform aneurysm presents higher risk than either condition alone, making intervention more strongly indicated 2
• Fusiform aneurysms are more challenging to treat than saccular aneurysms and may require specialized techniques during surgery 2, 3
• Conservative management of extracranial ICA aneurysms has historically resulted in high mortality rates (up to 71%), supporting the need for intervention 2
• Anatomic factors should be carefully assessed when selecting between CEA, CAS, or TCAR, as approximately 21% of carotid lesions may be ineligible for CEA due to high extension 4
• For patients with hostile aortic arch anatomy, TCAR may be preferred over transfemoral CAS 4