From the Guidelines
A 50% left internal carotid artery (ICA) stenosis in an 82-year-old female is generally not considered clinically relevant for surgical intervention but does warrant medical management. The recommended approach is antiplatelet therapy with aspirin 81-325 mg daily or clopidogrel 75 mg daily if aspirin intolerant, as indicated by the guidelines for the prevention of stroke in patients with stroke or transient ischemic attack 1. Statin therapy is also indicated, typically atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily, regardless of baseline cholesterol levels. Blood pressure should be controlled to a target below 140/90 mmHg using appropriate antihypertensives. Lifestyle modifications including smoking cessation, diabetes management, regular exercise, and a Mediterranean or DASH diet are essential components of care.
- Key aspects of management include:
- Antiplatelet therapy to reduce the risk of stroke
- Statin therapy to stabilize plaques and reduce inflammation
- Blood pressure control to reduce the risk of stroke and cardiovascular disease
- Lifestyle modifications to address modifiable risk factors This approach is recommended because carotid revascularization (endarterectomy or stenting) is typically reserved for symptomatic patients with ≥50% stenosis or asymptomatic patients with ≥70% stenosis, as outlined in the guidelines 1. The benefit-to-risk ratio for surgical intervention in an 82-year-old with moderate stenosis is unfavorable, as the annual stroke risk with 50% asymptomatic stenosis is only about 1-2% with medical therapy, while procedural risks increase with age, as noted in the primary prevention of ischemic stroke guideline 1. Regular follow-up with carotid ultrasound every 6-12 months is advised to monitor for progression of stenosis.
From the Research
Treatment Options for Carotid Stenosis
- Carotid endarterectomy (CEA) and carotid angioplasty with stenting (CAS) are two treatment options for carotid stenosis, with CEA being superior to medical therapy for patients with symptomatic severe stenosis 2.
- The decision to use invasive procedures should weigh the long-term risk reduction in ipsilateral ischemic stroke against the immediate intervention risks 2.
- CAS may be equally effective and safe as CEA in treating individuals with asymptomatic carotid stenosis, but the evidence is not conclusive 3.
Comparison of CEA and CAS
- CEA is associated with a reduced incidence of stroke at follow-up compared to CAS, especially in patients with severe symptomatic stenosis 4, 5.
- CAS is associated with a higher risk of periprocedural death or stroke, especially in patients older than 70 years 5.
- CEA has a lower risk of myocardial infarction, cranial nerve palsy, and access site hematoma compared to CAS 5.
Management of Carotid Stenosis
- All patients with carotid stenosis should receive aggressive medical therapy, including antiplatelet agents, statins, blood pressure reduction, weight control, and smoking cessation 2, 6.
- Carotid revascularization with either CEA or CAS can benefit select patients with severe stenosis, but the choice of treatment should be individualized based on patient characteristics and comorbidities 6, 4, 5.