What is the recommended first‑line management for internal carotid artery stenosis >70% in symptomatic versus asymptomatic patients?

Management of Internal Carotid Artery Stenosis >70%

Symptomatic Patients (Recent TIA or Stroke)

For symptomatic patients with >70% ICA stenosis, 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

• Initiate dual antiplatelet therapy (DAPT) with low-dose aspirin and clopidogrel 75 mg immediately for at least 21 days if revascularization is delayed or the patient is not a candidate for urgent surgery. 1, 2

• After the initial 21-day period, transition to long-term single antiplatelet therapy with either clopidogrel 75 mg or aspirin. 1

• Start optimal medical therapy (OMT) including high-intensity statin therapy, blood pressure control, smoking cessation, and lifestyle modifications regardless of whether revascularization is performed. 1, 2

Surgical Intervention Timing and Selection

• CEA is the gold standard treatment for symptomatic 70-99% stenosis and should be performed as soon as the patient is neurologically stable after 48 hours but definitely within 14 days. 1, 3

• The benefit of CEA increases with stenosis severity, and early intervention prevents stroke recurrence during the high-risk period immediately following the initial event. 1

• For symptomatic patients with 50-69% stenosis, CEA should be considered if the 30-day procedural risk remains <6%. 1

Alternative to CEA

• Carotid artery stenting (CAS) should be considered for high surgical risk patients with 70-99% stenosis, provided the documented 30-day risk of procedural death/stroke is <6%. 1

• CAS may be considered for patients <70 years of age with 70-99% stenosis, though CEA remains preferred. 1

• Registry data shows higher complication rates with transfemoral CAS compared to CEA, particularly in older patients. 4

Post-Procedural Management

• After CEA, continue long-term single antiplatelet therapy (aspirin or clopidogrel). 1

• After CAS, continue DAPT with aspirin and clopidogrel for at least 1 month, then transition to long-term single antiplatelet therapy. 1

• Perform duplex ultrasound surveillance within the first month after revascularization. 1

Critical Assessment Requirements

• All symptomatic patients must be assessed by a vascular team including a neurologist. 1

• Use the NASCET method or its non-invasive equivalent to confirm stenosis severity; the ECST method overestimates stenosis and should not be used. 1, 2

• Duplex ultrasound is the first-line imaging modality for diagnosis and follow-up. 1

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Asymptomatic Patients

For asymptomatic patients with >70% ICA stenosis, routine revascularization is NOT recommended in the absence of high-risk features and with life expectancy <5 years. 1

When to Consider Intervention in Asymptomatic Patients

• Revascularization may be considered in highly selected asymptomatic patients with 60-99% stenosis if all of the following criteria are met: 1

  • Life expectancy >5 years
  • Documented perioperative stroke/death rates <3%
  • Presence of high-risk features (contralateral occlusion, rapidly progressive stenosis, silent infarcts on imaging, impaired cerebrovascular reserve)
  • Patient is "average surgical risk" and >75 years of age

• In "high surgical risk" asymptomatic patients with 60-99% stenosis and high-risk features, CAS may be considered. 1

Medical Management for Asymptomatic Patients

• Initiate single antiplatelet therapy (aspirin or clopidogrel) for all asymptomatic patients. 2

• Implement comprehensive cardiovascular risk reduction including high-intensity statins, blood pressure control to target, smoking cessation, and Mediterranean-style diet. 2

• Annual follow-up to assess cardiovascular risk factors and treatment adherence. 1

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Common Pitfalls and Critical Considerations

• Do not delay CEA beyond 14 days in symptomatic patients—the risk of recurrent stroke is highest in the first two weeks, and delaying surgery eliminates much of the benefit. 1, 3

• Avoid CEA within the first 48 hours after major stroke due to increased risk of hemorrhagic transformation, particularly in patients with large infarcts (>1/3 middle cerebral artery territory), impaired consciousness, or pre-existing hemorrhage. 1

• Contralateral carotid occlusion is a high-risk feature that increases stroke risk in medically managed patients and should prompt consideration for revascularization even in borderline cases. 4

• The 30-day procedural risk threshold of <6% for symptomatic patients and <3% for asymptomatic patients is absolute—if your institution's complication rates exceed these thresholds, medical management alone is superior. 1

• In patients with "near-occlusion" (95-99% stenosis with distal ICA collapse or trickle flow), the benefit of CEA is less clear and requires careful individual assessment. 1