Do we stent the common carotid artery in cases of significant stenosis?

Common Carotid Artery Stenting

Common carotid artery (CCA) stenosis can be treated with stenting, but it is far less commonly performed than internal carotid artery (ICA) interventions, and the decision depends critically on whether the stenosis is symptomatic, the patient's surgical risk profile, and anatomic considerations.

Primary Treatment Approach

Symptomatic CCA Stenosis

• For symptomatic patients with ≥70% CCA stenosis, carotid endarterectomy (CEA) should be performed urgently (ideally within 2 weeks of the ischemic event), as this provides the strongest evidence for stroke prevention 1, 2.

• CEA is generally preferred over stenting for CCA lesions because the surgical access to the common carotid is technically straightforward, and the evidence base strongly supports CEA for extracranial carotid disease 1.

• Carotid artery stenting (CAS) may be considered for CCA stenosis when patients are not operative candidates due to technical, anatomic, or medical reasons 1. This includes:

  • Hostile neck anatomy (prior radiation, radical neck surgery) 1
  • Severe cardiac disease (NYHA class III/IV heart failure, recent MI) 1
  • Severe pulmonary disease 1
  • Contralateral laryngeal nerve palsy 1
  • Age >80 years with multiple comorbidities 1

Asymptomatic CCA Stenosis

• For asymptomatic CCA stenosis ≥60-70%, aggressive medical management is the cornerstone of initial treatment, including antiplatelet therapy, high-intensity statins (targeting LDL <55 mg/dL), and blood pressure control 3, 4.

• Routine revascularization is not recommended for asymptomatic CCA stenosis unless the patient has high-risk features AND life expectancy >5 years 3, 4.

• If revascularization is considered for asymptomatic disease, CEA is preferred over CAS, and should only be performed if the perioperative stroke/death rate is <3% 1, 5.

Age-Specific Considerations

• For patients >70 years old, CEA is generally more appropriate than CAS because stenting carries higher periprocedural stroke and death rates in older patients 1.

• For patients <70 years old with symptomatic stenosis, CAS may be considered as an alternative to CEA, though the evidence quality is lower 2.

Critical Performance Thresholds

For CEA:

• Perioperative stroke and death rates must be <6-7% for symptomatic stenosis 1
• Perioperative morbidity and mortality must be <3% for asymptomatic stenosis 1, 5

For CAS:

• Perioperative stroke and death rates must be <5% for symptomatic stenosis 1
• Perioperative morbidity and mortality must be <3% for asymptomatic stenosis 1

Anatomic Location Matters

• CCA stenosis (proximal, mid, or distal) can be treated with stenting, as demonstrated in early feasibility studies where 23 of 117 treated arteries involved the common carotid artery 6.

• The technical success rate for CCA stenting is high (97-99%), though neurological complications remain a concern 7, 6.

Common Pitfalls to Avoid

• Do not perform routine revascularization for asymptomatic CCA stenosis without high-risk features, as modern medical therapy has reduced stroke risk by 60-80% compared to older trial eras 3.

• Do not use CAS in patients >70 years old as first-line therapy when they are otherwise fit for surgery, as periprocedural stroke risk is significantly higher 1.

• Do not proceed with intervention if institutional complication rates exceed the evidence-based thresholds, as the benefit disappears when perioperative risk is too high 1, 5.

• Do not forget that embolic protection devices should be used during CAS when technically feasible, though they do not entirely prevent embolic events 7, 6.

Post-Intervention Management

• Continue aspirin 81-325 mg daily perioperatively and long-term after either CEA or CAS 5.

• **Initiate intensive lipid-lowering therapy targeting LDL-C <55 mg/dL** with >50% reduction 5.

• Perform duplex ultrasound surveillance within the first month post-procedure, then annually to detect restenosis or progression of contralateral disease 5.