What is the management algorithm for a patient with carotid stenosis?

Management Algorithm for Carotid Stenosis

Initial Assessment and Diagnosis

All patients with suspected carotid stenosis should undergo duplex ultrasound (DUS) as the first-line imaging modality, using the NASCET method to quantify stenosis severity. 1

• Stenosis measurement: Use peak systolic velocity (PSV) ≥230 cm/s to indicate ≥70% stenosis on DUS 2
• Confirm symptomatic vs asymptomatic status: Determine if the patient has experienced ipsilateral TIA, stroke, or amaurosis fugax within the past 6 months 1, 2
• Additional imaging: Consider CTA or MRA if DUS is inconclusive or to guide treatment planning 1

Management Pathway Based on Symptom Status and Stenosis Severity

SYMPTOMATIC Carotid Stenosis (Recent TIA/Stroke)

For 70-99% Stenosis:

Carotid endarterectomy (CEA) is recommended and should be performed within 14 days of symptom onset, provided the perioperative stroke/death risk is <6%. 1, 3

• Immediate medical therapy: Start dual antiplatelet therapy (DAPT) with aspirin and clopidogrel 75 mg for 21 days, then transition to single antiplatelet therapy (clopidogrel 75 mg or aspirin) 1, 3
• Statin therapy: Initiate high-intensity statin targeting LDL-C <70 mg/dL (or <55 mg/dL per European guidelines) 3, 2
• Blood pressure control: Target <140/90 mmHg 3, 2
• Urgent vascular team evaluation: Assessment by neurologist and vascular specialist is mandatory 1

For 50-69% Stenosis:

CEA is recommended but provides more modest benefit (absolute risk reduction ~6.5% vs 17% for 70-99% stenosis). 1

• Apply same medical therapy as above 1
• Consider patient-specific factors including age, comorbidities, and life expectancy when deciding on revascularization 1

For <50% Stenosis:

Revascularization is NOT recommended; medical therapy alone is indicated. 1

• DAPT for 21 days minimum, then single antiplatelet therapy 1
• Aggressive risk factor modification with statins, blood pressure control, smoking cessation 4, 5

ASYMPTOMATIC Carotid Stenosis

For ≥70% Stenosis:

Carotid artery stenting (CAS) plus intensive medical management is superior to intensive medical management alone and should be considered in appropriately selected patients. 2

• Patient selection criteria: Life expectancy >5 years, perioperative risk <3%, absence of high surgical risk features 1, 2
• High-risk features favoring intervention: Contralateral TIA/stroke, ipsilateral silent infarction on brain imaging, stenosis progression >20%, spontaneous embolization on transcranial Doppler, impaired cerebrovascular reserve, echolucent plaques or intraplaque hemorrhage 2
• Note: Routine revascularization is NOT recommended in patients with life expectancy <5 years or absence of high-risk features 1

Medical Management for All Asymptomatic Patients:

Intensive medical therapy has reduced annual stroke risk to ≤1% per year and is mandatory regardless of stenosis severity. 2, 4, 5

• Antiplatelet therapy: Low-dose aspirin 75-100 mg daily (if bleeding risk is low) 2, 6
• High-intensity statin: Target LDL-C <55 mg/dL 2
• Blood pressure control: Target <140/90 mmHg (or <130/80 mmHg if tolerated) 2
• Smoking cessation: Mandatory—the 60-70% decline in stroke rates from 1995-2010 was partly attributed to reduced smoking 2
• Diabetes management: Optimize glycemic control 2, 4

Perioperative Management for Revascularization

For CEA:

• Continue aspirin perioperatively—do not discontinue 3
• Carotid patch angioplasty is preferable to primary closure 7
• Aspirin 75-325 mg daily and statins should be given before, during, and following CEA 7

For CAS:

• DAPT with aspirin and clopidogrel is required for at least 1 month post-procedure 1, 7
• Use embolic protection devices 7
• Perform only in high-volume centers with documented low perioperative stroke/death rates 7

Post-Revascularization Follow-Up

Duplex ultrasound surveillance within the first month after revascularization is mandatory to assess for restenosis. 1, 3

• Long-term antiplatelet therapy: Continue single antiplatelet therapy (aspirin or clopidogrel) indefinitely 1, 3
• Annual follow-up: Check cardiovascular risk factors and treatment compliance yearly 1, 2
• Continued aggressive risk factor modification: Maintain statin therapy, blood pressure control, and lifestyle modifications indefinitely 3, 2

Surveillance for Non-Revascularized Patients

• Annual duplex ultrasound to monitor stenosis progression 2
• Reassess for intervention if stenosis progresses ≥2 categories in 1 year (significantly elevated ipsilateral ischemic event risk) 2
• Monitor adherence to antiplatelet therapy, statin therapy, and cardiovascular risk factor control 2

Critical Pitfalls to Avoid

• Do NOT perform revascularization for stenosis <50% except in extraordinary circumstances 1
• Do NOT revascularize chronic total occlusions of the carotid artery 1
• Do NOT screen asymptomatic populations for carotid stenosis—there is no evidence that screening reduces stroke 2
• Do NOT use the ECST method for stenosis assessment; use NASCET method only 1
• Do NOT delay CEA beyond 14 days in symptomatic patients—benefit decreases significantly with time 1, 3
• Do NOT perform CEA if perioperative stroke/death risk exceeds 6% for symptomatic patients or 3% for asymptomatic patients 1, 7