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Carotid artery stenosis

Last updated: February 12, 2021

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Carotid artery stenosis (CAS) is an atherosclerotic, degenerative disease of the common carotid artery and internal carotid artery. Risk factors include advanced age, tobacco use, arterial hypertension, and diabetes mellitus. Depending on the extent of stenosis, ischemia in the carotid perfusion territory can result in amaurosis fugax, TIA, or stroke, and a bruit may be auscultated over the stenosis. Carotid duplex ultrasonography is the initial test of choice for evaluating asymptomatic patients. All symptomatic patients should undergo noncontrast CT or MRI to rule out acute or previous cerebral ischemia. Management depends on symptoms and the degree of stenosis. Lifestyle modifications and antiplatelet, antihypertensive, and statin therapy are recommended for all patients. Carotid endarterectomy is recommended for symptomatic patients with a stenosis ≥ 70% and asymptomatic patients with a stenosis ≥ 80%, but may also be considered in highly selected patients with moderate stenosis. Alternatively, if surgery is not feasible, carotid artery stenting may be performed.

Carotid artery stenosis does not typically cause vertigo, lightheadedness, or syncope.

References:[2][3]

  • Interventional management: decision to pursue intervention depends on the patient’s symptoms, degree of stenosis, and risk factors
    • Carotid endarterectomy (CEA): a surgical procedure in which the inner lining of a carotid artery is removed, along with any associated atherosclerotic deposits.
      • Indications
        • Symptomatic patients
          • Carotid artery stenosis ≥ 70%
          • Moderate carotid artery stenosis (50%–69%): depends on patient's age, sex, and comorbidities
        • Asymptomatic patients
          • Carotid artery stenosis ≥ 80%
          • Moderate carotid artery stenosis (60%–79%): depends on patient's age, sex, and comorbidities
      • Contraindications
        • Life expectancy of < 5 years
        • Symptomatic carotid artery stenosis < 50%
        • Asymptomatic complete carotid occlusion
        • Prior ipsilateral endarterectomy
        • Perioperative risk of a stroke/death: ≥ 6% in symptomatic patients; ≥ 3% in asymptomatic patients
        • History of prior neck surgery/irradiation
    • Carotid artery stenting (CAS): angioplasty and stenting as an alternative to CEA
      • May be considered if surgery is not feasible
      • Increased risk of periprocedural complications compared to CEA

References:[3][4][5][6][7]

References:[5]

We list the most important complications. The selection is not exhaustive.

References:[5][8]

  1. Kaufman EJ, Mahabadi N, Patel BC. Hollenhorst Plaque. StatPearls. 2020 .
  2. Furie KL. Pathophysiology of Symptoms from Carotid Atherosclerosis. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/pathophysiology-of-symptoms-from-carotid-atherosclerosis.Last updated: January 31, 2017. Accessed: April 7, 2017.
  3. Furie KL. Evaluation of Carotid Artery Stenosis. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/evaluation-of-carotid-artery-stenosis.Last updated: January 30, 2015. Accessed: April 7, 2017.
  4. Fairman RM. Management of Symptomatic Carotid Atherosclerotic Disease. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/management-of-symptomatic-carotid-atherosclerotic-disease.Last updated: October 19, 2016. Accessed: December 7, 2016.
  5. Fairman RM. Management of Asymptomatic Carotid Atherosclerotic Disease. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/management-of-asymptomatic-carotid-atherosclerotic-disease.Last updated: June 24, 2016. Accessed: December 7, 2016.
  6. Carotid Artery Stenosis. https://www.dynamed.com/topics/dmp~AN~T116329/Carotid-artery-stenosis. Updated: June 7, 2017. Accessed: December 21, 2017.
  7. Ricotta JJ, AbuRahma A, Ascher E, Eskandari M, Faries P, Lal BK. Updated Society for Vascular Surgery guidelines for management of extracranial carotid disease. J Vasc Surg. 2011; 54 (3): p.e1-e31. doi: 10.1016/j.jvs.2011.07.031 . | Open in Read by QxMD
  8. Rodriguez AL. Atherosclerotic Disease of the Carotid Artery. In: Lopez Rowe V, Atherosclerotic Disease of the Carotid Artery. New York, NY: WebMD. http://emedicine.medscape.com/article/463147. Updated: April 8, 2016. Accessed: April 7, 2017.