From the Guidelines
Management of 50-69% internal carotid artery (ICA) stenosis should primarily focus on optimal medical therapy (OMT) rather than immediate surgical intervention. The approach to managing this degree of stenosis involves aggressive medical management, including antiplatelet therapy, statin therapy, blood pressure control, and lifestyle modifications. According to the 2024 ESC guidelines for the management of peripheral arterial and aortic diseases 1, revascularization is not recommended in patients with ICA lesions <50%, and by extension, this conservative approach can be applied to those with 50-69% stenosis, given the lack of specific recommendations for this range. Key components of medical therapy include:
- Antiplatelet therapy, such as aspirin 81-325 mg daily or clopidogrel 75 mg daily if aspirin is contraindicated
- Statin therapy, with high-intensity statins like atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily, aiming for LDL levels below 70 mg/dL
- Blood pressure control, targeting levels below 140/90 mmHg (or lower for diabetic patients) using appropriate antihypertensives
- Lifestyle modifications, including smoking cessation, regular physical activity, weight management, and a Mediterranean or DASH diet Regular follow-up with carotid ultrasound every 6-12 months is recommended to monitor for disease progression 1. Carotid revascularization (endarterectomy or stenting) is generally not recommended for this degree of stenosis unless there are recurrent symptoms despite optimal medical therapy. This approach prioritizes minimizing morbidity, mortality, and improving quality of life by avoiding the risks associated with unnecessary surgical interventions.
From the Research
Management of 50-69% iCA Stenosis
- The management of asymptomatic internal carotid artery (iCA) stenosis depends on various factors, including the severity of stenosis and the presence of vulnerable plaque features 2.
- For patients with 50-69% iCA stenosis, medical management alone is often advocated, as it has been shown to reduce the risk of stroke to comparable rates seen with carotid endarterectomy (CEA) or carotid artery stenting (CAS) 2, 3.
- However, invasive treatment may be considered in selected patients with severe stenosis and life expectancy exceeding 5 years, or in symptomatic patients with stenosis greater than 70% and in selected patients with recent symptoms and moderate (50% to 69%) stenosis 3.
- Carotid endarterectomy (CEA) and carotid angioplasty and stenting (CAS) are both effective treatment options for asymptomatic carotid stenosis, with similar outcomes over the long-term 4, 5.
Comparison of CEA and CAS
- Studies have compared the efficacy and safety of CEA and CAS in patients with asymptomatic carotid stenosis, with mixed results 4, 5, 6.
- A systematic review and meta-analysis found that CAS was associated with a decreased risk of myocardial infarction (MI) and a slightly increased risk of stroke, although not significant, compared to CEA 5.
- Another meta-analysis found that CEA was associated with a lower early all stroke risk compared to CAS, although other early or late outcomes did not show any difference between the two methods 6.
Medical Management
- Medical management remains the mainstay of treatment in patients with asymptomatic carotid stenosis, and has been shown to reduce the risk of stroke to comparable rates seen with CEA or CAS 2, 3.
- Best medical treatment (BMT) has been compared to CEA and CAS in several studies, with results suggesting that CEA may have a benefit over BMT against long-term ipsilateral stroke, although early outcomes are worse after CEA 6.