What is the recommended management for carotid artery stenosis in an adult patient based on symptom status (recent transient ischemic attack, amaurosis fugax, or stroke), degree of stenosis, surgical risk, and comorbidities?

Management of Carotid Artery Stenosis

Symptomatic Carotid Stenosis (Recent TIA, Amaurosis Fugax, or Stroke Within 6 Months)

For symptomatic patients with 70-99% stenosis, carotid endarterectomy (CEA) is the definitive treatment and must be performed within 14 days—ideally within the first few days after neurological stabilization—if the surgeon's documented perioperative stroke/death rate is <6%. 1

Severe Stenosis (70-99%)

• CEA provides substantial benefit with 2-year ipsilateral stroke risk of 9% versus 26% with medical therapy alone 1, 2
• Surgery within 2 weeks is critical: delaying beyond 14 days significantly reduces stroke-free survival 1, 2
• When performed within 1 week, CEA has perioperative stroke/death rates of 1.3% versus 8.3% for carotid artery stenting (CAS) 3
• CEA is strongly preferred over CAS for patients ≥70 years of age due to higher perioperative stroke risk with stenting (hazard ratio 2.09 for ages 70-74) 3, 1

Moderate Stenosis (50-69%)

• CEA is recommended if perioperative risk <6%, but benefit is substantially lower than severe stenosis 1
• Patient-specific factors matter: age >65 years, male sex, recent stroke (versus TIA), and life expectancy >5 years favor intervention 1
• Women with 50-69% stenosis showed no clear benefit in NASCET trial—consider medical therapy alone 1
• Number needed to treat is 77 patients over 5 years to prevent one stroke 2

Stenosis <50%

• No indication for revascularization by either CEA or CAS (Class III recommendation) 1
• Medical therapy only 1

Role of Carotid Artery Stenting (CAS)

• CAS is acceptable only for patients <70 years with average or low endovascular risk when stenosis >70% by noninvasive imaging or >50% by catheter angiography 1
• CAS may be considered for high surgical risk due to: radiation-induced stenosis, restenosis after prior CEA, hostile neck anatomy (high bifurcation, contralateral vocal cord paralysis), or severe cardiac/pulmonary comorbidities 1, 3
• Operator must demonstrate perioperative stroke/death rates of 4-6% 1

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Asymptomatic Carotid Stenosis

For asymptomatic patients, CEA may be considered only for stenosis ≥60-70% in highly selected individuals with life expectancy >5 years and documented surgeon perioperative stroke/death rate <3%. 2, 4, 5

Critical Selection Criteria

• Life expectancy must exceed 5 years because benefit emerges only after 2-3 years 1, 2
• Surgeon/center must routinely audit outcomes and demonstrate <3% perioperative complication rate 2, 4
• Modern medical therapy has reduced annual stroke risk to <1% in asymptomatic patients—revascularization benefit is marginal 5, 6
• Most contemporary guidelines specify CEA "may be provided" rather than "should be provided" for asymptomatic stenosis 1, 4

High-Risk Plaque Features (Consider Intervention)

• Large lipid cores, intraplaque hemorrhage, thin fibrous caps <165 μm, surface ulceration, or documented plaque progression 7
• Markers of plaque neovascularization or inflammation on advanced imaging 5

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Mandatory Medical Therapy for ALL Patients

Optimal medical therapy is non-negotiable regardless of whether revascularization is performed and includes antiplatelet therapy, high-intensity statin, blood pressure control, smoking cessation, and diabetes management. 1, 2, 4

Specific Medical Regimen

• Antiplatelet therapy: aspirin 75-325 mg daily 1
• Statin therapy: target LDL <70 mg/dL (1.8 mmol/L) with high-dose statin 1, 2
• Blood pressure control: aggressive management per stroke prevention guidelines 1, 2
• Smoking cessation: mandatory 2, 4
• Diabetes management: glucose control with target HbA1c <7% 1
• Avoid dual antiplatelet therapy (aspirin + clopidogrel) within 3 months after stroke or TIA 1

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Critical Quality Benchmarks

The operating surgeon and center must routinely audit performance and demonstrate perioperative stroke/death rates <6% for symptomatic patients and <3% for asymptomatic patients—if these benchmarks are not met, revascularization should not be offered. 1, 2, 3

• Operators must have documented experience with ≥20 cases using proper technique and independent neurological evaluation 1
• Randomized trials achieved 5-7% combined perioperative stroke/death rates—real-world practice must match this 3

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Common Pitfalls and How to Avoid Them

Timing Errors

• Do not delay CEA beyond 14 days in neurologically stable symptomatic patients—benefit decreases substantially with delay 1, 3, 8
• Do not operate in the hyperacute period (<48 hours) if patient has large infarct or unstable neurological deficit—wait for stabilization 8

Patient Selection Errors

• Do not perform revascularization for stenosis <50% (Class III recommendation)—this provides no benefit 1, 3
• Do not offer CEA to asymptomatic patients with life expectancy <5 years or surgeon complication rate >3% 1, 2
• Do not select CAS over CEA in patients ≥70 years unless compelling surgical contraindications exist 3, 1

Measurement Errors

• Use NASCET method for stenosis measurement (comparing narrowest diameter to normal distal internal carotid artery) 3
• Confirm stenosis severity with CTA or MRA if duplex ultrasound is equivocal 5

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Follow-Up Requirements

Annual follow-up is mandatory to assess neurological symptoms, cardiovascular risk factors, medication adherence, and duplex ultrasound surveillance for restenosis. 2, 4

• Duplex ultrasound within first month after revascularization, then periodically 2
• Monitor for new neurological symptoms, progression of contralateral stenosis, and cardiovascular events 4