Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Review
. 2025 Apr 15;121(1):13-43.
doi: 10.1093/cvr/cvad135.

Stroke risk management in carotid atherosclerotic disease: a clinical consensus statement of the ESC Council on Stroke and the ESC Working Group on Aorta and Peripheral Vascular Diseases

Piotr Musialek  1 , Leo H Bonati  2 , Richard Bulbulia  3   4 , Alison Halliday  4 , Birgit Bock  5 , Laura Capoccia  6 , Hans-Henning Eckstein  7 , Iris Q Grunwald  8   9 , Peck Lin Lip  10 , Andre Monteiro  11 , Kosmas I Paraskevas  12 , Anna Podlasek  9   13 , Barbara Rantner  14 , Kenneth Rosenfield  15 , Adnan H Siddiqui  16   17 , Henrik Sillesen  18   19 , Isabelle Van Herzeele  20 , Tomasz J Guzik  21   22 , Lucia Mazzolai  23 , Victor Aboyans  24 , Gregory Y H Lip  25   26
Affiliations
Review

Stroke risk management in carotid atherosclerotic disease: a clinical consensus statement of the ESC Council on Stroke and the ESC Working Group on Aorta and Peripheral Vascular Diseases

Piotr Musialek et al. Cardiovasc Res. .

Abstract

Carotid atherosclerotic disease continues to be an important cause of stroke, often disabling or fatal. Such strokes could be largely prevented through optimal medical therapy and carotid revascularization. Advancements in discovery research and imaging along with evidence from recent pharmacology and interventional clinical trials and registries and the progress in acute stroke management have markedly expanded the knowledge base for clinical decisions in carotid stenosis. Nevertheless, there is variability in carotid-related stroke prevention and management strategies across medical specialities. Optimal patient care can be achieved by (i) establishing a unified knowledge foundation and (ii) fostering multi-specialty collaborative guidelines. The emergent Neuro-Vascular Team concept, mirroring the multi-disciplinary Heart Team, embraces diverse specializations, tailors personalized, stratified medicine approaches to individual patient needs, and integrates innovative imaging and risk-assessment biomarkers. Proposed approach integrates collaboration of multiple specialists central to carotid artery stenosis management such as neurology, stroke medicine, cardiology, angiology, ophthalmology, vascular surgery, endovascular interventions, neuroradiology, and neurosurgery. Moreover, patient education regarding current treatment options, their risks and advantages, is pivotal, promoting patient's active role in clinical care decisions. This enables optimization of interventions ranging from lifestyle modification, carotid revascularization by stenting or endarterectomy, as well as pharmacological management including statins, novel lipid-lowering and antithrombotic strategies, and targeting inflammation and vascular dysfunction. This consensus document provides a harmonized multi-specialty approach to multi-morbidity prevention in carotid stenosis patients, based on comprehensive knowledge review, pinpointing research gaps in an evidence-based medicine approach. It aims to be a foundational tool for inter-disciplinary collaboration and prioritized patient-centric decision-making.

Keywords: Antithrombotic management; Atherosclerotic carotid disease; Biomarkers; Evidence base; Imaging; Interventional management; Multi-specialty team; Neuro-Vascular team; Recent trials and registries; State-of-the art review; Stroke risk reduction.

PubMed Disclaimer

Conflict of interest statement

Conflict of interest. P.M.: Co-principal Investigator in the CGUARDIANS FDA-IDE and in the CARENET Trial. Principal investigator in the PARADIGM/PARADIGM-Extend, FLOWGUARD, OPTIMA, TOPGUARD, and SAFEGUARD-STROKE Investigator-Initiated Trials. Member of the European Society of Cardiology (ESC) Research and Grants Committee and ESC Congress Programme Committee. Voting member of the ESC WG CARE. Member of the EuroPCR VITAL. Proctor and/or consultant for the Abbott Vascular, Balton, Gore, InspireMD, and Medtronic. Grants from the Polish Committee for Scientific Research, Polish Cardiac Society, and the Jagiellonian University Medical College for research related to carotid artery disease. CArotid Revascularization systematic reviews and MEta-aNalyses (CARMEN) Collaboration. Polish Cardiac Society Board Representative for Stroke and Vascular Interventions. L.H.B.: Lead author of the 2021 European Stroke Organisation (ESO) guideline on endarterectomy and stenting for carotid artery stenosis. Principal investigator in the Precise-MRI. Co-principal investigator in the ECST-2 and ACST-2. Investigator in the ICSS, lead investigator in the ICSS-MRI sub-study. Consultant for the AstraZeneca. Grants from the Swiss National Science Foundation, the Swiss Heart Foundation, the University of Basel, and AstraZeneca for research related to carotid artery disease. R.B.: Co-author of the 2021 ESO guideline on endarterectomy and stenting for carotid artery stenosis, reviewer of the European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease and co-principal investigator in the ACST-2. A.H.: Co-author of the ESVS 2023 Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease, co-author of the 2021 ESO guideline on endarterectomy and stenting for carotid artery stenosis, and co-author of the ESC Guidelines on dyslipidaemias. Principal investigator in the ACST-1 and ACST-2. Steering Committee member of the ECST-2 and ICSS. Carotid Stenting Trialists' Collaboration (CSTC). Chair of the ESC Stroke Council. B.B., P.L.L., A.M., A.P., and T.J.G.: No conflicts of interest. L.C.: ACST-2 collaborator. Investigator-Initiated Studies of CEA and CAS. H.-H.E.: Co-author of the 2021 ESO guideline on endarterectomy and stenting for carotid artery stenosis, reviewer of the ESVS 2023 Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease, and lead author in the multidisciplinary German–Austrian guideline on the diagnosis, treatment and follow-up of extracranial carotid stenosis. Steering Committee of the SPACE-1, co-principal investigator in the SPACE-2, co-investigator in the ROADSTER 1 and ROADSTER 2, and co-investigator in the ACST-2 and CSTC. EU Horizon 2020 grant for stratification of carotid disease. I.Q.G.: Principal investigator on the first trial of mechanical thrombus aspiration in acute stroke (Penumbra). Investigator-Initiated Studies of acute stroke and CAS. Lead author of the World Federation for Interventional Stroke Treatment (WIST) multispecialty training guidelines for endovascular stroke intervention. Co-founder of the Brainomix. Research funding from the Samsung Neurologica and Johnson&Johnson and educational grant from Pulsara. Vice President of the WIST. K.I.P.: Lead author of reviews on carotid revascularization by CEA and CAS. Lead author of commentaries on the European and US carotid revascularization guidelines. Initiator of Delphi consensus document on controversial issues in the management of patients with asymptomatic and symptomatic carotid stenosis and of Delphi consensus document on transcarotid stent-assisted revascularization. B.R.: Co-chairperson of the writing committee of the ESVS 2023 Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease. Co-Investigator in ACST-2 and CSTC. K.R.: Writing committee for the American College of Cardiology/American Heart Association (ACC/AHA) Peripheral Arterial Disease (PAD) Guidelines, ACC/AHA Competency Statement for treatment of PAD, and Trans-Atlantic Inter-Society Consensus Document on Management of Peripheral Arterial Disease (TASC) II. Chair of Multidisciplinary writing task force developing guidelines for training, competence, and credentialing for carotid intervention, co-ordinated (through ACC/SVS/SCAI) developing novel modalities for training with the use of medical simulators and specialized training programmes (such as the FAME Programme). Consultant or on scientific advisory board for Althea Medical, Angiodynamics, Boston Scientific, Contego, InspireMD, Magneto, Mayo Clinic, Neptune Medical, Philips, Summa Therapeutics, Surmodics, Thrombolex, Terumo, and Truvic; has received institutional grant support from the National Institutes of Health, Abiomed, and Boston Scientific; owns equity interests in Accolade, Access Vascular, Aerami, Althea Medical, Contego, Cruzar Systems, Embolitech, Endospan, InspireMD, JanaCare, Magneto, Orchestra, PQ Bypass, Prosomnus, Shockwave, Summa Therapeutics, Thrombolex, Truvic, and Valcare. Member of the Society for Cardiovascular Angiography and Intervention (SCAI), Ad hoc Carotid and Cerebrovascular Disease Committee, member of Multispecialty Carotid Alliance. Chairperson of the Peripheral Arterial Disease Committee of the ACC, Chair of the SCAI Ad hoc Committee on PAD. A.H.S.: Society of Neurointerventional Surgery Standards and Guidelines Committee, and Multispecialty Carotid Alliance. Grants from National Institutes of Health/National Institute of Neurological Disorders and Stroke (co-principal investigator on Optimizing Approaches to Endovascular Therapy of Acute Ischemic Stroke; co-investigator on Virtual Intervention of Intracranial Aneurysms) and has served as the national principal investigator for or on the Steering Committee of the Cerenovus EXCELLENT and ARISE II trial; the Medtronic SWIFT PRIME, VANTAGE, EMBOLISE, and SWIFT DIRECT trials; the MicroVention FRED trial and CONFIDENCE study; the MUSC POSITIVE trial; the Penumbra 3D Separator trial, COMPASS trial, INVEST trial, MIVI neuroscience EVAQ trial; and the Rapid Medical SUCCESS trial. He owns financial interest in, is an investor in, owns stock options, or has ownership in Adona Medical, Amnis Therapeutics, Bend IT Technologies, BlinkTBI, Buffalo Technology Partners, Cardinal Consultants, Cerebrotech Medical Systems, Cerevatech Medical, Cognition Medical, CVAID, Endostream Medical, Imperative Care, Instylla, International Medical Distribution Partners, Launch NY, NeuroRadial Technologies, Neurotechnology Investors, Neurovascular Diagnostics, PerFlow Medical, Q’Apel Medical, QAS.ai, Radical Catheter Technologies, Rebound Therapeutics (purchased 2019 by Integra Lifesciences), Rist Neurovascular (purchased 2020 by Medtronic), Sense Diagnostics, Serenity Medical, Silk Road Medical, Spinnaker Medical, StimMed, Synchron, Three Rivers Medical, Truvic Medical, Vastrax, VICIS, and Viseon; has served as a consultant or on the advisory board for Amnis Therapeutics, Apellis Pharmaceuticals, Boston Scientific, Canon Medical Systems USA, Cardinal Health 200, Cerebrotech Medical Systems, Cerenovus, Cerevatech Medical, Cordis, Corindus, Endostream Medical, Imperative Care, Integra, IRRAS AB, Medtronic, MicroVention, Minnetronix Neuro, Penumbra, Q’Apel Medical, Rapid Medical, Rebound Therapeutics, Serenity Medical, Silk Road Medical, StimMed, Stryker Neurovascular, Three Rivers Medical, VasSol, Viz.ai, and W.L. Gore and Associates. Past Secretary—Society of Neurointerventional Surgery, past Chair—Joint Cerebrovascular Section of the American Association of Neurological Surgeons, and Council of State Neurosurgical Societies. H.S.: Writing committee of European Society for Vascular Surgery 2023 Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease. I.V.H.: Writing group of ESO guideline on endarterectomy and stenting for carotid stenosis, and a member of ESVS Guideline Committee. Co-Investigator in the ACST-2, Precise-MRI, and TOPGUARD. Research support from the SilkRoad Medical. Consultant for Medtronic; Institution support from the Simbionix. L.M.: Chair of the ESC Working Group on Aorta and Peripheral Vascular Diseases. V.A.: ESC Chairperson of the Task Force/Authors of the 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases (developed in collaboration with ESVS). Consultant and/or speaker for the Amgen, AstraZeneca, Bayer Healthcare, BMS, Boehringer Ingelheim, Lilly, NovoNordisk, Pfizer. Past Chair of the ESC Working Group on Aorta and Peripheral Vascular Diseases. G.Y.H.L.: Consultant and/or speaker for BMS/Pfizer, Boehringer Ingelheim, and Daiichi Sankyo (no personal honoraria). Chairperson-Elect of the ESC Council on Stroke.

Similar articles

See all similar articles

Cited by

See all "Cited by" articles

Publication types

MeSH terms