What is the management plan for carotid artery stenosis in the neck?

Management of Carotid Artery Stenosis

All patients with carotid artery stenosis require immediate initiation of intensive medical therapy, with revascularization decisions based on symptom status, degree of stenosis, and patient age.

Initial Diagnostic Workup

Begin with duplex Doppler ultrasound as the primary screening and surveillance tool for carotid stenosis evaluation 1. This modality is accurate, non-invasive, and avoids radiation or contrast exposure.

When to Add Advanced Imaging

• Use CTA neck with IV contrast when multivessel cerebrovascular disease or very severe stenosis is present, as Doppler may artifactually over- or underestimate disease severity 1
• Use MRA neck (with or without contrast) as an alternative to CTA for anatomic assessment, particularly helpful in multivessel disease or severe stenosis 1
• Important caveat: CTA may underestimate stenosis with heavy calcifications or tortuosity, and overestimate near-occlusive stenosis 1
• Important caveat: Noncontrast MRA may overestimate severe/near-occlusive stenosis; contrast administration reduces this overestimation 1

Medical Management (All Patients)

Antiplatelet Therapy

For symptomatic patients (recent stroke/TIA within 6 months):

• Start clopidogrel 75 mg daily immediately while awaiting vascular consultation 2, 3
• Continue dual antiplatelet therapy (aspirin 81-325 mg + clopidogrel 75 mg) for 90 days post-event 3
• After 90 days, transition to single agent: aspirin 75-325 mg daily, clopidogrel 75 mg daily, or aspirin plus extended-release dipyridamole (25/200 mg twice daily) 1, 2

For asymptomatic patients with ≥70% stenosis:

• Start aspirin 75-325 mg daily to prevent myocardial infarction and other ischemic events 2
• Alternative: clopidogrel 75 mg daily 2

Additional Medical Therapy

• High-potency statin regardless of baseline lipid levels 3, 4
• Blood pressure control with goal <140/90 mmHg 3, 4
• Smoking cessation and Mediterranean-style diet 3
• Antihypertensive medication before and after any revascularization procedure 1

Revascularization Decisions

Symptomatic Patients (Stroke/TIA within 6 months)

For 70-99% stenosis:

• Perform revascularization within 2 weeks of the index event rather than delaying 1, 2
• Choose carotid endarterectomy (CEA) over carotid artery stenting (CAS) for patients >70 years old 2
• CAS is acceptable for younger patients (<70 years) with favorable anatomy 5, 6

For 50-69% stenosis:

• Consider revascularization only if surgeon's perioperative stroke/death rate is <6% 3
• Otherwise, intensive medical therapy alone is preferred 3

For <50% stenosis:

• Do not perform revascularization except in extraordinary circumstances 1
• Intensive medical therapy only 1

Asymptomatic Patients

For ≥70% stenosis:

• Start intensive medical therapy immediately 2, 4
• CEA may be considered in highly selected patients, but effectiveness versus medical therapy alone remains uncertain 1, 4
• Important caveat: Modern medical therapy has rendered older trial data on endarterectomy benefits outdated; ongoing CREST-2 trial will clarify optimal management 1, 4
• Prophylactic CAS effectiveness is not well established 1

For 60-69% stenosis:

• Intensive medical therapy is primary treatment 4
• Revascularization effectiveness versus medical therapy alone is not well established 1

For <60% stenosis:

• Medical therapy only 1, 4

Contraindications to Revascularization

Do not perform revascularization in:

• Chronic total occlusion of the carotid artery 1
• Severe disability (Modified Rankin Scale ≥3) that precludes preservation of useful function 1
• High-risk patients with comorbidities (age ≥80, NYHA class III/IV heart failure, LVEF ≤30%, class III/IV angina, MI within 4 weeks, severe chronic lung disease) where effectiveness is not established 1

Periprocedural Management for CAS

Before and during CAS:

• Dual antiplatelet therapy with aspirin 81-325 mg + clopidogrel 75 mg for minimum 30 days 1, 2
• For clopidogrel intolerance, substitute ticlopidine 250 mg twice daily 1
• Deploy embolic protection device when vascular injury risk is low 1
• Document clinical neurological examination within 24 hours before and after procedure 1

Surveillance Imaging

After revascularization:

• Perform noninvasive imaging (duplex Doppler) at 1 month, 6 months, and annually to assess patency and detect new lesions 1
• Once stability is established, extend surveillance intervals 1
• Terminate surveillance when patient is no longer a candidate for intervention 1

For asymptomatic stenosis on medical therapy:

• Use duplex Doppler for surveillance 1
• Add CTA or MRA neck when multivessel disease or progression to severe stenosis is suspected 1
• MRI head without contrast can evaluate for silent strokes or microvascular ischemic changes in hemodynamically significant stenosis 1

Stenosis Classification

Carotid stenosis is categorized as:

• Mild: <50% stenosis 1
• Moderate: 50-69% stenosis 1
• Severe: ≥70% stenosis 1

The latter two categories have higher probability of hemodynamic significance and subsequent ipsilateral stroke 1.

Key Pitfalls to Avoid

• Do not delay revascularization beyond 2 weeks in symptomatic patients with severe stenosis 1, 2
• Do not rely solely on Doppler in multivessel disease or very severe stenosis—confirm with CTA or MRA 1
• Do not perform CAS in elderly patients (>70 years) when CEA is feasible—higher stroke risk with CAS in this population 2, 5, 6
• Do not forget dual antiplatelet therapy before CAS—critical for preventing periprocedural thrombotic events 1, 2
• Do not overlook coronary artery disease screening—50-75% of carotid stenosis patients have concomitant CAD 4