Carotid artery disease: clinical features and management

Abstract

The most common cause of ischaemic carotid territory stroke, around 50% of cases, is thromboembolism from stenoses at the origin of the extracranial internal carotid artery (ICA). Embolism is usually preceded by acute changes in plaque morphology, which predisposes towards overlying thrombus formation and embolization. The management of patients with carotid artery disease involves cardiovascular risk factor modification, antiplatelet and statin therapy in everyone. There is grade A, level I evidence that recently symptomatic patients with 50–99% stenoses gain significant benefit from carotid endarterectomy (CEA), despite a small risk of perioperative stroke. Maximum benefit is conferred if CEA is performed as soon as possible after onset of symptoms. Carotid artery stenting (CAS) is an alternative to CEA. Excluding operative risks, 9-year rates of ipsilateral stroke are virtually identical (i.e. CAS is durable), but (at present) 30-day death/stroke is significantly higher after CAS, compared to CEA. The management of patients with asymptomatic carotid stenoses (ACS) remains controversial. The 2018 European Society for Vascular Surgery (ESVS) carotid guidelines advise that patients with a 60–99% ACS who have one or more clinical/imaging features that make them ‘higher risk for stroke’ on best medical therapy (BMT) should be considered for CEA, with the remainder being treated medically.