Management of Severe Left Carotid Bifurcation Stenosis
For symptomatic patients with ≥70% left carotid bifurcation stenosis, carotid endarterectomy (CEA) should be performed urgently—ideally within 2 weeks of the neurological event—by a surgeon with perioperative stroke/death rates <6%. 1, 2
Symptomatic Patients (Recent TIA, Stroke, or Amaurosis Fugax)
Immediate Management
- Initiate dual antiplatelet therapy (aspirin plus clopidogrel) immediately after excluding hemorrhage on CT/MRI, as the risk of recurrent stroke is highest in the first 2 weeks. 3, 4
- Start high-intensity statin therapy targeting LDL <55 mg/dL regardless of baseline levels. 5, 6
- Optimize blood pressure to <140/90 mmHg (avoid aggressive lowering acutely to preserve cerebral perfusion). 1, 5
Revascularization Strategy
- CEA is the gold standard for symptomatic stenosis ≥70% and should be performed within 2 weeks (ideally within 48 hours to 14 days after neurological stability). 1, 2, 4
- For 50-69% symptomatic stenosis, CEA is recommended in selected patients considering age <75 years, male sex, and absence of significant comorbidities. 1, 2
- **The surgeon must have documented perioperative stroke/death rates <6%** for symptomatic patients; rates >6% negate any benefit. 1, 7
When to Consider CAS Instead of CEA
- CAS may be considered in patients <70 years old with symptomatic stenosis if they have high surgical risk due to: radiation-induced stenosis, restenosis after prior CEA, high/low carotid bifurcation anatomy, or severe cardiac/pulmonary comorbidities. 1, 2
- CAS requires embolic protection devices and dual antiplatelet therapy for ≥1 month post-procedure. 5, 2
- Avoid CAS in patients >70 years due to higher periprocedural stroke risk compared to CEA. 2, 7
Asymptomatic Patients (No Ipsilateral Symptoms in Past 6 Months)
Medical Management First-Line
- Contemporary best medical therapy has reduced annual stroke risk to ≤1%, making it the preferred initial approach for most asymptomatic patients. 5, 6
- Core medical therapy includes: daily aspirin 75-100 mg, high-intensity statin (LDL <55 mg/dL), blood pressure control (<140/90 mmHg), smoking cessation, and diabetes management. 5, 6, 8
When to Consider Intervention
CEA may be considered for asymptomatic stenosis 70-99% only if all of the following criteria are met: 1, 5, 7
- Perioperative stroke/death rate <3% at the treating center
- Life expectancy >5 years
- Age <70 years (benefit diminishes with age)
- Male sex (women derive less benefit)
- High-risk features present: contralateral carotid occlusion, rapid stenosis progression (≥2 categories in 1 year), silent ipsilateral infarcts on imaging, or intraplaque hemorrhage
CAS for asymptomatic stenosis is not routinely recommended; the European Society of Cardiology assigns this a Class III recommendation (should not be done) unless part of a clinical trial. 5, 2
Surveillance Protocol
- Annual duplex ultrasound to monitor stenosis progression (PSV ≥230 cm/s indicates ≥70% stenosis). 1, 6, 8
- Reassess for intervention if stenosis progresses ≥2 categories in 1 year or if symptoms develop. 5, 6
- Annual cardiovascular risk factor assessment and medication adherence review. 5, 6
Critical Pitfalls to Avoid
- Do not operate on asymptomatic patients if the center's perioperative stroke/death rate exceeds 3%—this eliminates any potential benefit. 1, 5, 7
- Do not delay CEA in symptomatic patients—the 5-year absolute risk reduction is 5.9% when performed within 2 weeks but only 2.0% when delayed beyond 12 weeks. 2, 4
- Do not use CAS in elderly patients (>70 years) with symptomatic stenosis—CEA has superior outcomes in this population. 2, 7
- Do not stop medical therapy after revascularization—lifelong antiplatelet therapy, statin, and risk factor control remain essential as carotid stenosis reflects systemic atherosclerosis. 5, 6, 9
- Do not perform CEA for <50% symptomatic stenosis or <60% asymptomatic stenosis—there is no benefit and potential harm. 1, 7