What is the recommended management of significant arterial stenosis in an adult over 55 with typical atherosclerotic risk factors and possible ischemic symptoms?

Management of Significant Arterial Stenosis

All patients with significant arterial stenosis require immediate initiation of optimal medical therapy including high-intensity statin, antiplatelet therapy, blood pressure control, and cardiovascular risk factor modification, with revascularization decisions guided by stenosis location, symptom status, and specific high-risk features. 1

Carotid Artery Stenosis

Symptomatic Internal Carotid Artery (ICA) Stenosis

For symptomatic ICA stenosis ≥70%, perform carotid endarterectomy (CEA) within 14 days of symptom onset, provided your institution's documented perioperative stroke/death rate is <6%. 1, 2

• Initiate dual antiplatelet therapy (DAPT) with aspirin 81mg plus clopidogrel 75mg immediately upon diagnosis and continue for at least 21 days if revascularization is delayed 1, 2
• CEA is superior to carotid artery stenting (CAS) in patients >70 years of age, with registry data showing 1-year stroke/death rates of 5.2% for CEA versus 9.7% for CAS 3, 4
• For stenosis 50-69%, revascularization is not routinely recommended but should be discussed in the context of high-risk features 1, 5
• After CEA, discontinue clopidogrel and continue lifelong single antiplatelet therapy (aspirin or clopidogrel) 1

Asymptomatic ICA Stenosis

For asymptomatic ICA stenosis ≥60-70%, revascularization should only be considered when ALL of the following criteria are met: life expectancy >5 years, institutional perioperative stroke/death rate <3%, and presence of high-risk features. 1, 2

• High-risk features include: age >75 years, male sex, bilateral 70-99% stenosis or contralateral occlusion, ipsilateral silent cerebral infarction on imaging, rapid stenosis progression, and irregular or ulcerated plaque morphology 2, 6
• Recent CREST-2 trial data (2025) showed that among patients with high-grade asymptomatic stenosis, adding stenting to intensive medical management reduced 4-year stroke/death risk to 2.8% versus 6.0% with medical therapy alone (P=0.02), while endarterectomy showed no significant benefit (3.7% vs 5.3%, P=0.24) 7
• In asymptomatic patients with life expectancy <5 years or absence of high-risk features, routine revascularization is not recommended 1

Special Consideration: Contralateral Carotid Occlusion

Contralateral carotid occlusion is a high-risk feature that increases stroke risk, but should NOT be used as a reason to withhold revascularization in symptomatic patients with 70-99% stenosis. 3

• CEA remains the preferred method even with contralateral occlusion 3
• Continue DAPT through the perioperative period in these high-risk patients 3

Renal Artery Stenosis

Medical therapy is the primary treatment for atherosclerotic renal artery stenosis, with revascularization reserved only for specific refractory situations. 1

Atherosclerotic Renal Artery Stenosis

• Optimal medical management includes: antihypertensive regimen with renin-angiotensin system (RAS) blocker, high-intensity statin for LDL-C reduction, smoking cessation, hemoglobin A1c control in diabetes, and antiplatelet therapy 1
• Revascularization may be considered only when medical management has failed, defined as: refractory hypertension despite maximal therapy, progressive worsening renal function, or recurrent flash pulmonary edema (Pickering syndrome) 1
• For hemodynamically significant stenosis (70-99%, or 50-69% with post-stenotic dilatation), renal artery angioplasty and stenting may be considered in patients with recurrent heart failure, unstable angina, flash pulmonary edema, bilateral stenosis, or unilateral stenosis in a solitary kidney 1

Fibromuscular Dysplasia

Percutaneous transluminal renal angioplasty (PTRA) without stenting is the treatment of choice for fibromuscular dysplasia causing renovascular hypertension. 1

• This differs from atherosclerotic disease where medical therapy is preferred 1
• Consider screening for involvement of carotid, coronary, and other major arteries, as fibromuscular dysplasia is a systemic disease 1

Mandatory Medical Therapy for All Arterial Stenosis

Regardless of revascularization decisions, all patients require comprehensive cardiovascular risk reduction. 1

• Statin therapy: High-intensity statin to achieve LDL-C <55 mg/dL (<1.4 mmol/L) 1, 8
• Blood pressure control: Target <140/90 mmHg, using thiazide diuretics, ACE inhibitors, or angiotensin II receptor blockers 9
• Antiplatelet therapy: Single agent (aspirin or clopidogrel) for stable disease; DAPT for 21-90 days in acute symptomatic presentations 1, 9
• Smoking cessation: Mandatory intervention 9
• Diabetes management: Optimize glycemic control if present 1

Diagnostic Approach

Use duplex ultrasound (DUS) as the first-line imaging modality for all arterial stenosis evaluation. 1

• For carotid stenosis: Use NASCET method to quantify stenosis severity; confirm with CTA or MRA if DUS is inconclusive 1
• For renal artery stenosis: DUS first-line; if suspicious or inconclusive, proceed to MRA or CTA 1
• Bilateral arm blood pressure measurement is mandatory for all patients with peripheral arterial disease to screen for subclavian stenosis 1

Follow-Up Surveillance

Annual clinical follow-up is mandatory to assess cardiovascular risk factors and treatment compliance. 1

• Perform DUS within the first month after any revascularization procedure 1, 2
• Continue annual DUS surveillance to monitor disease progression 2, 9
• Assess neurological symptoms, cardiovascular risk factors, and medication adherence at each visit 1

Critical Pitfalls to Avoid

• Do not use anticoagulation (warfarin) for intracranial arterial stenosis—it is inferior to aspirin and increases bleeding risk 9
• Do not perform routine revascularization for asymptomatic subclavian or visceral artery stenosis 1
• Do not delay CEA beyond 14 days in symptomatic carotid stenosis—benefit decreases significantly with time 1, 2
• Do not use the ECST method for carotid stenosis quantification—NASCET is the validated standard 1
• Do not withhold RAS blockers in unilateral renal artery stenosis, but monitor renal function carefully in bilateral stenosis or stenosis of a solitary kidney 1