Carotid Artery Stenting: Indications and Guidelines
Primary Recommendation
Carotid artery stenting (CAS) should be reserved for specific high-risk scenarios where carotid endarterectomy (CEA) poses excessive surgical risk, with mandatory dual antiplatelet therapy and operator expertise demonstrating <6% perioperative stroke/death rates for symptomatic patients and <3% for asymptomatic patients. 1
Symptomatic Carotid Stenosis (Recent TIA/Stroke within 6 months)
When CAS Should Be Considered
CAS is appropriate for symptomatic patients with 70-99% stenosis who have specific anatomical or medical contraindications to CEA: 1
- Post-radiation stenosis or post-surgical stenosis 1
- Hostile neck anatomy: obesity, tracheostomy, contralateral laryngeal nerve palsy 1
- Anatomically challenging lesions: stenosis at different carotid levels, upper internal carotid artery stenosis 1
- Severe medical comorbidities contraindicating CEA: clinically significant cardiac disease requiring open heart surgery, severe pulmonary disease, contralateral carotid occlusion 1
Critical Performance Standards
The operating team must demonstrate documented perioperative stroke/death rates <6% for symptomatic patients. 1 This threshold is non-negotiable—benefit disappears if complication rates exceed this level. 2
Age Considerations
For patients ≥70 years of age, CEA should be selected over CAS to reduce perioperative stroke rates. 1 Older patients experience significantly higher stroke risk with stenting compared to surgery. 1, 3
Timing of Intervention
When revascularization is planned within 1 week of the index stroke, CEA is preferred over CAS. 1 Early intervention carries higher procedural risk with stenting. 3
Asymptomatic Carotid Stenosis
Primary Approach
Optimal medical therapy is the cornerstone of management for asymptomatic severe carotid stenosis, with routine revascularization NOT recommended. 2 Modern medical therapy has reduced stroke risk by 60-80% compared to older trial eras. 1, 2
When CAS May Be Considered (Highly Selective)
CAS may be considered only when ALL of the following criteria are met: 2, 3
- Life expectancy >5 years 2, 3
- Stenosis ≥60% by angiography, ≥70% by validated duplex ultrasound, or ≥80% by CTA/MRA 1, 3
- High-risk features for CEA present (anatomical or medical comorbidities as listed above) 1
- Documented operator/center perioperative stroke/death rate <3% 2, 3
- Patient preference after thorough discussion of risks versus medical therapy alone 1
Evidence Strength
Only 61% of contemporary guidelines endorse CAS for asymptomatic stenosis, and 29% explicitly oppose it. 1 The European Society of Cardiology gives a Class III recommendation (should NOT be done routinely) with Level A evidence against routine revascularization in asymptomatic patients. 2
Mandatory Antiplatelet Therapy
Dual antiplatelet therapy with aspirin and clopidogrel is required for patients undergoing CAS for at least 1 month. 1 This requirement typically delays elective cardiac surgery for 4-5 weeks if CAS is performed first. 1
Aspirin alone must be administered immediately before and after carotid revascularization. 1
Operator Proficiency Requirements
Operator volume and experience critically impact outcomes—mortality rates are higher with low-volume operators or those early in their experience. 1 The choice between CEA and CAS should be based on local expertise and documented complication rates. 1
Surveillance and Follow-Up
For patients managed medically (not undergoing revascularization): 2
- Serial duplex ultrasound at regular intervals to monitor progression 2
- Annual follow-up to assess neurological symptoms, cardiovascular risk factor control, and medication adherence 2, 3
For patients after CAS: 3
- Duplex ultrasound within the first month post-procedure 3
- Periodic surveillance to assess for restenosis 3
Critical Pitfalls to Avoid
Do not perform CAS in asymptomatic patients as routine practice—the 3% surgical complication threshold is critical, and benefit disappears if perioperative risk exceeds this. 2 The NASCET method must be used for stenosis measurement to ensure consistency with trial data. 1, 2
Do not use CAS in patients ≥70 years old unless compelling anatomical contraindications to CEA exist—age is a powerful predictor of worse outcomes with stenting. 1, 3
Do not proceed with CAS if the operator/center cannot document complication rates meeting guideline thresholds—operator proficiency is not optional. 1
Complementary Medical Management
Regardless of whether revascularization is performed, intensive medical therapy is mandatory: 1, 3