Management of patients with carotid artery stenosis

Abstract

A stenosis of the internal carotid artery may cause 10-20% of all ischemic strokes. Duplex ultrasound is the diagnostic cornerstone, and CT angiography or MR angiography may be used to confirm the severity of the stenosis or prior to revascularization. Catheter-based digital subtraction angiography is rarely needed for diagnostic purposes. In symptomatic patients, carotid revascularization is indicated in the presence of a stenosis >or= 50%. In asymptomatic patients, the indication for revascularization based on randomized trials is given at >or= 60% stenosis, as long as the estimated perioperative death or stroke risk is < 3%. In clinical practice, however, asymptomatic stenoses are usually treated only if luminal narrowing exceeds 70-80% and the patient has a life expectancy of at least 5 years. The choice of the revascularization strategy (endarterectomy vs. stenting) should be based on the patient's surgical risk profile and on the locally available expertise. Independently of the revascularization option, carotid artery stenosis patients remain at risk of cardiovascular events because of the high prevalence of associated coronary artery disease. A broad disease management focusing on risk factor and lifestyle modification may impact quality and duration of life of these patients to a greater extent than the revascularization procedure itself.