When is carotid artery stenting recommended for patients with carotid artery stenosis?

Carotid Artery Stenting Indications

Carotid artery stenting (CAS) should be reserved primarily for patients who are not candidates for carotid endarterectomy (CEA) due to technical, anatomic, or medical contraindications, as CEA remains the preferred revascularization method for most patients with significant carotid stenosis. 1

Primary Indications for CAS

Symptomatic Carotid Stenosis (50-99%)

CAS may be considered when CEA is contraindicated due to: 1

• Post-radiation stenosis - radiation-induced fibrosis makes surgical dissection hazardous 1
• Post-surgical restenosis after previous CEA 1
• Hostile neck anatomy including obesity, tracheostomy, or laryngeal nerve palsy 1
• High carotid bifurcation or stenosis at difficult surgical levels (upper internal carotid artery) 1
• Severe medical comorbidities contraindicating surgery, such as clinically significant cardiac disease requiring open-heart surgery, severe pulmonary disease, or recent myocardial infarction 2
• Contralateral carotid occlusion with high surgical risk 2

Asymptomatic Carotid Stenosis (60-99%)

CAS may be considered only in highly selected asymptomatic patients with: 1

• 60-99% stenosis with high-risk features (age >75 years, male sex, bilateral stenosis, contralateral occlusion, silent cerebral infarction, rapid progression, irregular/ulcerated plaque) 3, 4
• Life expectancy >5 years 1
• Documented institutional peri-procedural morbidity/mortality <3% 1
• Contraindications to CEA as listed above 1

Age-Related Considerations

CAS is generally NOT recommended for patients >70 years of age because current evidence demonstrates higher peri-procedural stroke and death rates compared to CEA in older patients. 1 However, CAS may be considered in younger patients (<70 years) with symptomatic stenosis ≥50-99% when surgical risk is prohibitive. 5

Absolute Contraindications to CAS

CAS should NOT be performed in patients with: 1

• Heavily calcified aortic arch or protruding atheroma that prevents safe catheter access
• Internal carotid artery lumen diameter <3 mm
• Contraindication to dual antiplatelet therapy (DAPT) - mandatory for at least 30 days post-procedure 1, 6

Mandatory Peri-Procedural Requirements

When CAS is performed, the following are essential: 1

• Interventionist/center with documented expertise and routine auditing of performance results
• Combined peri-procedural stroke and death rates ≤5% for symptomatic patients 1
• Combined peri-procedural stroke and death rates <3% for asymptomatic patients 1
• DAPT with aspirin and clopidogrel for minimum 30 days post-stenting 1, 6
• Embolic protection devices should be used when technically feasible 2

Timing Considerations for Symptomatic Patients

If CAS is chosen for symptomatic stenosis, perform within 14 days of the index ischemic event to maximize benefit and reduce recurrent stroke risk, provided the patient is clinically stable. 1, 3 Earlier intervention (within first few days) is ideal but must be balanced against hemorrhagic transformation risk. 1

Common Pitfall to Avoid

Do not perform CAS in routine asymptomatic patients or older patients (>70 years) when CEA is feasible - the evidence consistently shows CEA is superior in these populations with lower stroke/death rates. 1, 5 The only justification for CAS in these groups is when CEA carries prohibitive surgical risk due to the specific anatomic or medical contraindications listed above.

Mandatory Adjunctive Medical Therapy

All patients undergoing CAS require intensive medical therapy regardless of revascularization: 1, 3

• Antiplatelet therapy - DAPT for ≥21-30 days, then single antiplatelet therapy lifelong 1, 3, 6
• High-intensity statin therapy targeting LDL <70 mg/dL 1, 4
• Blood pressure control 1, 3
• Diabetes management 1
• Smoking cessation 1