Carotid endarterectomy in asymptomatic carotid stenosis patients

Best medical treatment, or risk factor management, is the first step in treatment for asymptomatic carotid stenosis. Considering the low stroke risk for patients with asymptomatic carotid stenosis treated with best medical treatment, most patients with asymptomatic carotid stenosis derive limited benefits from carotid revascularization procedures.

However, patients with asymptomatic carotid stenosis do remain at higher risk for future stroke and so may benefit from revascularization procedures.

According to the European Society for Vascular Surgery guidelines, carotid endarterectomy should be considered in patients with 60% to 99% stenosis, surgical risks of 3% or less, and a life expectancy greater than 5 years if they have 1 or more characteristics associated with increased risk of stroke. These characteristics include:

• the presence of micro-emboli on transcranial Doppler ultrasound
• plaque echolucency on carotid duplex ultrasound
• silent embolic infarcts on brain CT or MRI
• asymptomatic carotid stenosis progression
• decreased cerebrovascular reserve
• increasing size of juxta-luminal hypoechoic area
• carotid plaque ulceration
• intraplaque haemorrhage on MRI.

Note - carotid artery stenting is also recommended as an alternative to carotid endarterectomy in selected patients.

Reference

1. Naylor R et al. European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease. Eur J Vasc Endovasc Surg. 2023 Jan;65(1):7-111