Medical Management of Patients With Symptomatic Carotid Artery Stenosis

Abstract

Background: Level 1 evidence recommends that carotid endarterectomy (CEA) should be considered for symptomatic >50% internal carotid artery stenosis for stroke prevention. However, there is little contemporary data on the natural history of patients with symptomatic carotid artery stenosis who were managed with medical therapy alone. The aim of this study was to assess the outcomes of patients with symptomatic carotid artery stenosis who were managed medically.

Methods: This was a prospective observational study at a tertiary vascular referral center. The study period was from June 1, 2019, to January 1, 2024. Threshold for surgical intervention in patients with a symptomatic internal carotid artery was set at a stenosis of ≥70-99% as defined by societal guidelines. The primary outcome was stroke-free survival and all-cause mortality. Kaplan-Meier analysis was performed to assess stroke-free survival and all-cause mortality.

Results: There were 280 patients who were referred for management of symptomatic carotid artery stenosis during the study period. One-hundred fifty patients (69.4%) were treated with a CEA, 3 patients (1.4%) with carotid artery stenting, and the remaining 63 patients (29.2%) were managed medically. Of the patients managed medically, three patients (4.8%) developed a further ipsilateral ischemic stroke during the follow-up period. Any stroke-free survival for medically versus surgically managed patients at 1 and 4 years were both 94% vs. 94% and 88%, respectively. Overall, the medically managed patient group survival compared with those who had carotid intervention at 1 and 4 years were 88% and 57% vs. 97% and 88%, respectively.

Conclusion: Patients who underwent intervention for symptomatic carotid disease have better survival; however, risk of future ipsilateral stroke events appear to be comparable with patients who had medical management only. Larger studies are warranted to confirm the long-term outcomes between carotid surgery and medical management in symptomatic carotid artery stenosis.