Treatment

• All patients: Initiate secondary prevention strategies for ASCVD.

• Symptomatic carotid stenosis: Revascularization is typically indicated.

• Asymptomatic carotid stenosis: Consider revascularization for patients with severe carotid stenosis.

Carotid stenosis is a type of clinical ASCVD and measures to prevent further progression of atherosclerosis should be initiated in all patients and continued indefinitely (i.e., even after carotid revascularization).

• Lifestyle modifications: e.g., smoking cessation, heart-healthy diet

• Long-term antiplatelet therapy

• Long-term high-intensity statin therapy [16]

• Manage modifiable risk factors for atherosclerosis (e.g., diabetes mellitus, hypertension).

  
  

• Timing: ideally performed within 14 days of symptom onset

• Indications : Periprocedural risk and patient life-expectancy, comorbidities, and preferences must also be considered. [3][10][18]

  • Symptomatic carotid stenosis [17]

    • Severe carotid stenosis: Revascularization is indicated if life expectancy is ≥ 2 years and if the operator's risk of procedural morbidity and mortality is < 6%. [15]

    • Moderate carotid stenosis: The benefit of revascularization depends on patient-specific factors

  • Asymptomatic patients with severe carotid stenosis: Consider revascularization if the operator's risk of procedural morbidity and mortality risk is low (< 3%). [4][17]

• Contraindications [3][18]

  • Carotid stenosis < 50%

  • Chronic complete carotid occlusion

  • Severely disabling stroke

Carotid endarterectomy (CEA) is usually considered the first-line treatment for carotid stenosis. If the patient is not a good candidate for surgery or the lesion characteristics preclude surgical treatment, carotid artery stenting may be preferred.

• Carotid endarterectomy: a surgical procedure in which the inner lining of a carotid artery is removed, along with any associated atherosclerotic deposits

  • Advantages: lower periprocedural stroke rate than carotid artery stenting, especially in patients > 70 years of age

  • Disadvantages

    • Higher risk of periprocedural myocardial infarction than stenting

    • Potential complications include cranial nerve palsy.

    • Potentially difficult in patients with prior neck irradiation and/or surgery

• Carotid artery stenting: angioplasty and stenting of the carotid artery (via a transfemoral or transcarotid approach)

  • Advantages: an alternative to surgery in patients with poor surgical access or increased risk of perioperative complications

  • Disadvantages: higher risk of periprocedural stroke than CEA

• Carotid artery bypass grafting: Uncommonly required; may be considered for recurrent or bilateral severe carotid stenosis.

• Stroke : The annual risk of stroke is 0.5–1% in patients with asymptomatic carotid stenosis > 50%.

• Myocardial infarction

Recommendations for the screening for asymptomatic carotid stenosis vary. As of 2021, the US Preventive Services Task Force (USPSTF) recommends against screening for asymptomatic individuals, including those with cardiovascular risk factors and carotid bruits. However, other guidelines suggest screening for carotid stenosis in asymptomatic individuals with a carotid bruit and/or risk factors for cardiovascular disease who are potential candidates for carotid intervention.

• Indications: Consider screening for asymptomatic carotid stenosis in individuals with any of the followin

  • Carotid bruit (controversial)

  • Known atherosclerotic cardiovascular disease

  • Known peripheral vascular disease

  • Individuals ≥ 65 years of age with multiple risk factors for cardiovascular disease

  • Prior to a CABG

• Screening modalities: noninvasive imaging is preferred (e.g., CDUS, CTA, MRA)