Table 3.18-3. Recommended treatment of carotid artery stenosis

Degree of stenosis

Treatment

Patients with recent (<6 months) stroke or TIAa

<50%

Pharmacotherapy

50%-69%

– Consider revascularizationa,b,d

– Pharmacotherapy

70%-99%

– Revascularizationa,b,c

– Pharmacotherapy

Occluded or near-occluded

Pharmacotherapy

Patients without recent (<6 months) stroke or TIA

<60%

Pharmacotherapy

60%-99%

– Pharmacotherapy

– Consider revascularizationb,d in patients with life expectancy >5 years, favorable anatomy, and ≥1 feature suggesting higher risk of stroke with pharmacotherapye

Occluded or near-occluded

Pharmacotherapy

a Revascularization should be performed as soon as possible (<14 days).

b After a multidisciplinary discussion including neurologists.

c CEA is preferred. Consider CAS in patients at high risk for CEA (age >80 years, clinically significant cardiac disease, severe pulmonary disease, contralateral internal carotid artery occlusion, contralateral recurrent laryngeal nerve palsy, previous radical neck surgery or radiotherapy, recurrent stenosis after CEA).

d Consider CEA. CAS may be considered as a second choice.

e Contralateral TIA/stroke; ipsilateral silent infarction on cerebral imaging; ultrasonographic features: stenosis progression >20%, spontaneous embolization on transcranial Doppler, impaired cerebral vascular reserve, large (>40 mm2) or echolucent plaques, increased juxtaluminal hypoechogenic area; MRA features: intraplaque hemorrhage, lipid-rich necrotic core.

Adapted from Eur Heart J. 2018;39(9):763-816.

CAS, carotid artery stenting; CEA, carotid endarterectomy; CTA, computed tomography angiography; MRA, magnetic resonance angiography; TIA, transient ischemic attack.