From the Guidelines
Carotid Endarterectomy (CEA) is the recommended treatment for significant Internal Carotid Artery (ICA) stenosis, specifically for symptomatic patients with 70%–99% stenosis, provided the procedural death/stroke risk is <6%.
Treatment Options
- CEA is recommended for symptomatic 70%–99% ICA stenosis with a documented 30-day risk of procedural death/stroke <6% 1.
- CEA should be considered for symptomatic 50%–69% ICA stenosis with a documented 30-day risk of procedural death/stroke <6% 1.
- Carotid-Artery Angioplasty with Stenting (CAS) may be considered for symptomatic patients at high risk for CEA with 70%–99% ICA stenosis, or for symptomatic patients <70 years of age with 70%–99% ICA stenosis, provided the documented 30-day risk of procedural death/stroke is <6% 1.
Timing of Intervention
- CEA should be performed within 14 days in symptomatic ICA stenosis patients, if indicated 1.
- CAS may be considered within 2 weeks of the index event, rather than delayed surgery, to increase the likelihood of a stroke-free outcome 1.
Contraindications
- Revascularization is not recommended in patients with ICA lesions <50% 1.
From the Research
Treatment Options for Significant Internal Carotid Artery (ICA) Stenosis
- Carotid endarterectomy (CEA) is a preferred method of management for patients with significant ICA stenosis, particularly those with symptomatic severe carotid stenosis 2, 3, 4.
- Carotid artery stenting (CAS) is another less invasive surgical option that has similar outcomes over the long-term, especially in patients with high surgical risk due to anatomic or clinical variables 2, 3, 5, 4.
- Medical management alone is also advocated for patients with asymptomatic carotid stenosis, as recent improvements in medical management have reduced the risk of stroke in this population to comparable rates seen with CEA 2.
- The choice of treatment depends on various factors, including the severity of stenosis, plaque morphology, and patient characteristics such as age, surgical risk, and presence of symptoms 3, 4.
Considerations for Symptomatic vs. Asymptomatic ICA Stenosis
- Symptomatic patients with significant ICA stenosis are at higher risk of stroke and may benefit from earlier surgical intervention, such as CEA or CAS 3, 4.
- Asymptomatic patients with significant ICA stenosis may be managed with medical therapy alone, but invasive treatment may be considered in selected patients with severe stenosis and life expectancy exceeding 5 years 2, 4.
Recent Advances and Ongoing Research
- The Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial (CREST-2) is an ongoing study aiming to compare the effectiveness of CEA, CAS, and medical management for asymptomatic carotid stenosis 2.
- Advances in endovascular techniques, such as carotid artery stenting, have expanded the treatment options for patients with significant ICA stenosis, particularly those with high surgical risk or anatomical constraints 5.