From the Guidelines
Carotid stenosis of 70% or greater requires intervention in symptomatic patients. This recommendation is based on the most recent and highest quality study, the 2024 ESC guidelines for the management of peripheral arterial and aortic diseases 1. According to these guidelines, carotid endarterectomy (CEA) is recommended for symptomatic patients with 70%–99% internal carotid artery (ICA) stenosis, provided the documented 30-day risk of procedural death/stroke is less than 6%.
For asymptomatic patients, the guidelines do not specify a exact percentage for intervention, but it is generally considered at 80% or greater stenosis. The primary interventions include carotid endarterectomy (CEA) or carotid artery stenting (CAS).
- The decision to intervene should be individualized based on surgical risk, life expectancy, and patient preferences.
- Medical therapy is always recommended regardless of intervention status and includes antiplatelet therapy, high-intensity statin therapy, blood pressure control, smoking cessation, and diabetes management.
- Revascularization is not recommended in patients with ICA lesions <50% 1. Intervention aims to prevent stroke by removing or bypassing the atherosclerotic plaque that could potentially embolize to the brain or cause flow-limiting stenosis.
From the Research
Carotid Stenosis and Intervention
- Carotid stenosis is a significant cause of ischemic stroke, and patients with symptoms of stroke or transient ischemic attack attributable to a significantly stenotic vessel (70-99% luminal narrowing) should be treated with intensive medical therapy 2.
- For symptomatic carotid stenosis, current guidelines put a threshold of 70% for formal indication for revascularization, but revascularization should be discussed for symptomatic stenosis over 50% and for asymptomatic carotid stenosis over 60% 3.
- The management of asymptomatic carotid stenosis is more complex, with some studies suggesting that carotid endarterectomy (CEA) can be beneficial for patients with significant (≥60%?, ≥70%?) stenosis who have a life expectancy of more than 5 years 4.
- The 2022 Society for Vascular Surgery clinical practice guidelines recommend that patients with asymptomatic ≥70% stenosis can be considered for carotid endarterectomy (CEA), transcarotid artery revascularization (TCAR), or transfemoral carotid artery stenting (TFCAS) for the reduction of long-term risk of stroke, provided the patient has a life expectancy of 3 to 5 years with risk of perioperative stroke and death not exceeding 3% 5.
- In patients with symptomatic carotid stenosis, endarterectomy is highly beneficial, and the absolute benefit is increased in patients with 70-99% stenosis, men, patients over 75 years, and in those treated within 2 weeks after the last event 6.
Intervention Thresholds
- Symptomatic carotid stenosis: 70% threshold for formal indication for revascularization 2, 3.
- Asymptomatic carotid stenosis: 60% or 70% threshold for consideration of revascularization 3, 4, 5.
- Patients with asymptomatic ≥70% stenosis can be considered for carotid endarterectomy (CEA), transcarotid artery revascularization (TCAR), or transfemoral carotid artery stenting (TFCAS) for the reduction of long-term risk of stroke 5.