What is the recommended treatment for a patient with symptomatic carotid stenosis?

Management of Symptomatic Carotid Stenosis

For patients with symptomatic carotid stenosis ≥70%, carotid endarterectomy (CEA) should be performed within 14 days of symptom onset, provided the documented 30-day risk of procedural death/stroke is <6%. 1

Immediate Medical Management (All Patients)

Antiplatelet Therapy

• Initiate dual antiplatelet therapy (DAPT) with aspirin plus clopidogrel 75 mg immediately for at least 21 days if revascularization is delayed or not planned 1
• DAPT reduces asymptomatic cerebral embolization and stroke recurrence after minor stroke/TIA 1
• Continue DAPT through the perioperative period to reduce thromboembolic risk 2

Intensive Medical Therapy (Mandatory for All)

• High-dose statin therapy (atorvastatin 80 mg daily) targeting LDL <55-70 mg/dL 3, 4
• Blood pressure control with target <140/90 mmHg 3
• Smoking cessation, Mediterranean-style diet, and regular exercise 3, 4
• ACE inhibitors as part of cardiovascular risk reduction 5

Revascularization Algorithm by Stenosis Severity

70-99% Stenosis (Strong Indication)

• CEA is the preferred revascularization method with Class I, Level A recommendation 1
• Perform within 14 days of symptom onset to maximize benefit 1, 2
• The 30-day procedural stroke/death risk must be documented at <6% 1
• CEA reduces stroke risk significantly, with benefit increasing with stenosis severity 2

50-69% Stenosis (Conditional Indication)

• CEA should be considered if the surgeon's perioperative stroke/death rate is <6% 6
• Less benefit from revascularization compared to higher-grade stenosis 6
• Medical therapy alone may be appropriate if procedural risk exceeds 6% 6

<50% Stenosis (No Revascularization)

• Revascularization is not recommended (Class III, Level A) 1
• Intensive medical therapy only 1

Special Considerations

Contralateral Carotid Occlusion

• Do not withhold revascularization based solely on contralateral occlusion 2
• This is a high-risk feature that increases stroke risk in medically managed patients 2
• CEA remains preferred over carotid artery stenting (CAS), as registry data shows 1-year stroke/death rates of 5.2% for CEA versus 9.7% for transfemoral CAS 1, 2

High Surgical Risk Patients

• CAS may be considered as an alternative to CEA in patients with high surgical risk 1, 3
• Transcarotid artery revascularization (TCAR) shows promising results with 99.7% technical success and <3% 30-day stroke/death rates 1
• However, CEA remains the gold standard when feasible 1

Perioperative Antiplatelet Management

For CEA

• Continue aspirin 75-325 mg daily perioperatively 3
• Discontinue clopidogrel after CEA and transition to long-term single antiplatelet therapy (aspirin or clopidogrel) 1, 2

For CAS

• Continue DAPT with aspirin plus clopidogrel for at least 1 month post-procedure 1, 3
• Then transition to single antiplatelet therapy 3

Post-Revascularization Follow-Up

• Perform duplex ultrasound surveillance within the first month after revascularization 1, 3
• Annual follow-up is mandatory to assess neurological symptoms, cardiovascular risk factors, and treatment adherence 1, 3
• Continue long-term single antiplatelet therapy (aspirin or clopidogrel) indefinitely 1, 2
• Maintain intensive medical therapy including statins and blood pressure control 2, 3

Critical Pitfalls to Avoid

• Do not delay revascularization beyond 14 days in eligible symptomatic patients, as the risk of recurrent stroke is highest in the early period 1, 7
• Do not use the ECST method for stenosis assessment; use NASCET method or its non-invasive equivalent 1
• Do not perform revascularization if the center's documented 30-day stroke/death rate exceeds 6% for CEA 1
• Do not withhold DAPT in the acute phase due to concerns about bleeding risk unless there is active hemorrhage 1