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. 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 cautious approach can be applied to those with 50-69% stenosis, especially in asymptomatic cases. The guidelines emphasize the importance of OMT for all symptomatic ICA stenosis patients 1.
Key components of OMT include:
- Antiplatelet therapy, such as aspirin 81-325 mg daily or clopidogrel 75 mg daily for aspirin-intolerant patients
- High-intensity statin therapy, typically with atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily, aiming for LDL levels below 70 mg/dL
- Blood pressure control to less than 140/90 mmHg (or lower if tolerated) using appropriate antihypertensives
- Diabetes management targeting HbA1c below 7%
- Lifestyle modifications including smoking cessation, regular physical activity, a Mediterranean or DASH diet, and limiting alcohol consumption
Regular follow-up with carotid ultrasound every 6-12 months is crucial to monitor for disease progression 1. Carotid endarterectomy or stenting may be considered for symptomatic patients with recent TIA or stroke if they have favorable surgical risk, but this decision should be made on a case-by-case basis, weighing the potential benefits against the risks of the procedure. The approach outlined prioritizes stroke prevention through risk factor modification while avoiding unnecessary surgical risks in patients with moderate stenosis, as the benefit-to-risk ratio of revascularization is not clearly favorable in this stenosis range 1.
From the Research
Management of 50-69% iCA Stenosis
- The management of asymptomatic internal carotid artery (ICA) stenosis involves surgical and medical options, including carotid endarterectomy (CEA) and carotid artery stenting (CAS) 2.
- Studies have shown that CEA and CAS are effective in reducing the risk of stroke in patients with asymptomatic carotid stenosis, with similar outcomes over the long-term 3, 4.
- A meta-analysis found that CEA is 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 5.
- Medical management alone is also advocated for patients with asymptomatic carotid stenosis, as improvements in medical management have reduced the risk of stroke in this population to comparable rates seen with CEA 2.
Risk of Stenosis Progression
- The risk of stenosis progression increases as the severity of ICA stenosis increases, with patients with stenosis rates of above 50% being at a higher risk of stenosis progression than those with stenosis rate of < 50% 6.
- Hyper-LDL-cholesterolemia (Hyper-LDL-c) also increases the risk of stenosis progression, with an adjusted odds ratio of 2.22 (p = 0.03; 95% CI: 1.05~4.71) 6.
- Patients with ICA stenosis severity >50% and Hyper-LDL-c have high rates of stenosis progression, and annual follow up through carotid artery ultrasonography may be necessary 6.
Treatment Options
- CEA and CAS are both effective treatment options for patients with asymptomatic carotid stenosis, with similar outcomes over the long-term 3, 4.
- Medical management alone is also a viable option, as improvements in medical management have reduced the risk of stroke in this population to comparable rates seen with CEA 2.
- The choice of treatment option depends on various factors, including the severity of stenosis, plaque morphology, and patient characteristics 2, 5.