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Neurology - Carotid Stenosis - Fast Facts | NEJM Resident 360

Carotid stenosis can be symptomatic (i.e., cause of syncope or transient ischemic attack [TIA]/stroke) or asymptomatic (i.e., incidentally discovered during preoperative cardiac-surgery screening or as a carotid bruit on physical exam, although no evidence exists to recommend screening for carotid bruits).

The following table reviews tests to detect carotid stenosis:

Management

• Medical management (for asymptomatic and symptomatic carotid stenosis) includes cholesterol-lowering drugs (statins), blood pressure–lowering drugs, and antiplatelet agents. For symptomatic stenoses from 50% to 69%, medical management is usually preferred, although men may benefit more than women.

• Carotid endarterectomy (CEA) is a major vascular surgery that is reserved for symptomatic and, rarely, high-grade asymptomatic carotid stenosis.

• Carotid stenting (CAS) is an interventional procedure that is used for symptomatic and, rarely, high-grade asymptomatic carotid stenosis, including cases not amenable to CEA.

Indications for carotid stenosis intervention (CEA and CAS):

• The most common indication for CEA is in a patient with a symptomatic carotid lesion (i.e., history of ipsilateral TIA or ischemic stroke) and >70% stenosis.

• For symptomatic stenoses from 50% to 69%, men may benefit more than women, but medical management is usually preferred in both groups. These recommendations were in part established by the North American Symptomatic Carotid Endarterectomy Trial (NASCET) trial in 1991 (see the Research section for access to the full article). The goal of CEA is to prevent a disabling stroke.

• CEA is rarely considered in asymptomatic patients who are good operative candidates with high-grade stenosis. The Asymptomatic Carotid Atherosclerosis Study (ACAS) in 1995 established that CEA reduced the risk of stroke by half in healthy patients with 60% stenosis or higher (read the NEJM Journal Watch summary). However, this benefit was only seen when performed at high-volume centers with low perioperative stroke risks, and therefore it is not commonly performed for asymptomatic indications.

• These studies (NASCET and ACAS) did not compare CEA to current optimal medical management. In practice, guidelines for CEA are changing with better medical management of carotid disease.

• CEA is the procedure of choice for most patients with carotid stenosis. However, recently, CAS has emerged as an option based on two major trials:

• The Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) study established safety and efficacy of CAS compared with CEA in patients less than 80 years old. Read more about the CREST study in NEJM Journal Watch and this blog post.

• The Asymptomatic Carotid Trial (ACT) I studied older patients (age 79 and older) with asymptomatic carotid stenosis of 70-99% who were at standard surgical risk and found that stenting was non-inferior to endarterectomy in several outcomes including stroke and death. (see NEJM Journal Watch summary)

• Because the benefits of revascularization with CEA are often delayed, the patient’s life expectancy should be sufficiently longer to realize this benefit.

• Medical management and reduction of modifiable lifestyle factors should accompany surgical revascularization, and aspirin should be used prior to and after surgery.

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