What is the recommended treatment for internal carotid artery (ICA) stenosis?

Management of Internal Carotid Artery Stenosis

All patients with ICA stenosis require optimal medical therapy (OMT) as the foundation of treatment, with revascularization decisions based on symptom status, stenosis severity, surgical risk, and life expectancy. 1

Symptomatic ICA Stenosis

Immediate Medical Management

• Initiate dual antiplatelet therapy (DAPT) with aspirin and clopidogrel immediately for at least 21 days to reduce early recurrent stroke risk in all symptomatic patients, regardless of revascularization plans. 1, 2
• DAPT may be extended up to 90 days considering bleeding risk. 1
• All symptomatic patients must be assessed by a multidisciplinary vascular team including a neurologist. 1

Revascularization Indications by Stenosis Severity

For stenosis ≥70-99%:

• Carotid endarterectomy (CEA) is the treatment of choice and should be performed within 14 days of symptom onset to maximize stroke prevention benefit, provided perioperative stroke/death risk is <6%. 1, 2
• The benefit of surgery increases with stenosis severity in this range. 1

For stenosis 50-69%:

• CEA plus OMT reduces stroke risk compared to OMT alone, though the benefit is less pronounced than with higher-grade stenosis. 1
• Revascularization should still be performed within 14 days if undertaken. 2

For stenosis <50%:

• CEA does not prevent stroke and is not recommended (Class III recommendation). 1
• Continue aggressive OMT with DAPT for at least 21 days. 1

Critical Timing Considerations

• Perform revascularization within 14 days of the index neurological event (TIA or minor stroke) to achieve maximum benefit. 1, 2
• Controversy exists regarding revascularization within the first 48 hours due to increased hemorrhagic transformation risk. 1
• Avoid early revascularization in high-risk patients: those with acute carotid occlusion, major neurological deficit, middle cerebral artery infarction exceeding one-third territory, pre-existing parenchymal hemorrhage, or impaired consciousness. 1

CEA vs. Carotid Artery Stenting (CAS)

• CEA remains the preferred treatment for symptomatic stenosis due to lower 30-day stroke rates compared to CAS. 1, 2, 3
• CAS may be considered in high surgical risk patients with severe medical comorbidities, hostile neck anatomy (radiation-induced stenosis, high-riding plaques, restenosis after prior CEA), or contralateral occlusion, provided the complication rate does not exceed 6%. 1, 2, 3
• CAS has higher rates of minor periprocedural stroke but similar long-term outcomes to CEA. 1, 4
• Transcarotid artery revascularization (TCAR) shows promising registry data with 1-year stroke/death rates of 6.4% versus 5.2% for CEA and 9.7% for transfemoral CAS, though no randomized trials exist. 1

Special Consideration: Contralateral Carotid Occlusion

• Contralateral occlusion is a high-risk feature that increases stroke risk in medically managed patients. 1, 5
• Do not withhold revascularization based solely on contralateral occlusion—the long-term benefit of CEA may be even more pronounced in this subgroup. 5
• CEA remains the preferred method over CAS in this population. 5

Asymptomatic ICA Stenosis

When to Consider Revascularization

Revascularization should only be considered when ALL of the following criteria are met: 1, 2

• Stenosis ≥60-99% by NASCET criteria
• Life expectancy >5 years
• Documented institutional perioperative stroke/death rate <3%
• Presence of high-risk features

High-Risk Features Justifying Intervention

The following features identify asymptomatic patients at increased stroke risk who may benefit from revascularization: 1, 2

• Age >75 years
• Male sex
• Bilateral 70-99% stenosis or contralateral occlusion
• Ipsilateral silent cerebral infarction on imaging
• Rapid progression of stenosis
• Irregular or ulcerated plaque morphology
• Tandem intracranial stenosis
• Failure to recruit intracranial collaterals

Revascularization Method Selection

• For average surgical risk patients >75 years with 60-99% stenosis and high-risk features, CEA plus OMT should be considered (Class IIa recommendation). 1
• For high surgical risk patients with 60-99% stenosis and high-risk features, CAS plus OMT may be considered (Class IIb recommendation). 1
• For average surgical risk patients, CAS may be considered as an alternative to CEA (Class IIb recommendation). 1

When NOT to Revascularize

• In asymptomatic patients without high-risk features or with life expectancy <5 years, routine revascularization is not recommended (Class III recommendation). 1
• Modern medical therapy has reduced stroke rates to levels comparable with surgical intervention in many asymptomatic patients. 6, 7

Optimal Medical Therapy (Universal for All Patients)

All patients with ICA stenosis, regardless of revascularization status, require: 1, 2

• High-intensity statin therapy for plaque stabilization
• Blood pressure control (target <140/90 mmHg, <130/80 mmHg if diabetic)
• Diabetes management (HbA1c <7%)
• Smoking cessation
• Long-term single antiplatelet therapy (aspirin or clopidogrel) after the acute phase

Antiplatelet Management Algorithm

For symptomatic patients not immediately revascularized:

• DAPT (aspirin + clopidogrel) for at least 21 days, up to 90 days considering bleeding risk. 1, 2

For patients undergoing CEA:

• Continue DAPT through the perioperative period if symptomatic. 5
• Discontinue clopidogrel after surgery. 1, 5
• Continue long-term single antiplatelet therapy (SAPT). 1, 2

For patients undergoing CAS:

• Continue DAPT for 4 weeks post-procedure. 1
• Transition to long-term SAPT thereafter. 1, 2

Follow-Up Surveillance

All patients require: 2

• Duplex ultrasound within the first month after revascularization
• Annual duplex ultrasound to monitor disease progression
• Annual clinical follow-up to assess cardiovascular risk factors and medication compliance

Critical Pitfalls to Avoid

• Do not perform revascularization for stenosis <50% in symptomatic patients—it provides no benefit and exposes patients to procedural risk. 1
• Do not delay revascularization beyond 14 days in symptomatic patients with ≥50% stenosis—the benefit diminishes significantly with time. 1, 2
• Do not accept institutional perioperative stroke/death rates >6% for symptomatic patients or >3% for asymptomatic patients—medical therapy alone is superior at higher complication rates. 1, 2
• Do not use CAS as first-line therapy in elderly patients (>70 years)—CEA has superior outcomes in this population. 2, 3, 4
• Do not forget that even patients with <50% stenosis require aggressive medical management—they remain at cardiovascular risk. 8
• Do not overlook near-occlusion lesions (95-99% with distal ICA collapse)—these do not benefit from surgery as much as 70-94% stenosis. 1