Carotid artery stenosis

Last updated: July 21, 2022

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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, transient ischemic attack (TIA), or stroke. Carotid duplex ultrasonography is the initial test of choice for evaluating the carotid artery and measuring the degree of stenosis. Management depends on the degree of stenosis and patient factors (e.g., life-expectancy, comorbidities). Lifestyle modifications, antiplatelet and statin therapy, and risk factor modifications (e.g., with antihypertensive therapy) are recommended for all patients and should be continued indefinitely. Carotid revascularization is recommended for severe carotid stenosis and may be considered for moderate carotid stenosis if the periprocedural risks are acceptable. Screening for asymptomatic carotid stenosis is controversial.

  • Symptomatic carotid stenosis: symptoms attributable to carotid stenosis within the past 6 months
  • Asymptomatic carotid stenosis: no recent (< 6 months) symptoms attributable to carotid artery stenosis

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

General principles [3][4][5]

Noncontrast CT head or MRI brain is indicated for all patients with ischemic stroke or TIA.

Carotid artery stenosis typically occurs within 2 cm of the common carotid artery bifurcation. [6]

Carotid duplex ultrasound (CDUS)

CDUS permits direct visualization of the vessel wall and flow measurement at the site of the stenosis by color Doppler ultrasound.

  • Indications: first-line imaging modality for suspected symptomatic carotid stenosis [7][8]
  • Findings [4][6][9]
    • Focally increased velocity of blood flow (high-grade stenosis) or absence of blood flow (total occlusion) [10]
    • Increased peak systolic velocity
    • Increased thickness of the intima-media

Magnetic resonance angiography (MRA) or CT angiography (CTA)

  • Indications [4]
  • Findings [8]
    • Luminal narrowing at the site of the stenosis
    • Carotid plaques and calcification
  • Additional considerations

Digital subtraction angiography (DSA)

DSA is commonly considered the gold standard for evaluating CAS. [5][8][12]

  • Indications [4]
  • Findings: Similar to CTA or MRA
  • Important consideration: DSA is an invasive procedure with a higher risk of mortality and stroke than imaging modalities with comparable diagnostic accuracy (e.g., CTA).

General principles [3][4][13]

Medical management [3][15]

Carotid stenosis is a type of clinical ASCVD and measures to prevent further progression of atherosclerosis should be initiated in all patients and continued indefinitely (i.e., even after carotid revascularization).

Carotid revascularization

Overview [3][15][17]

Modalities [4][13][17]

Carotid endarterectomy (CEA) is usually considered the first-line treatment for carotid stenosis. If the patient is not a good candidate for surgery or the lesion characteristics preclude surgical treatment, carotid artery stenting may be preferred.

  • Carotid endarterectomy: a surgical procedure in which the inner lining of a carotid artery is removed, along with any associated atherosclerotic deposits
  • Carotid artery stenting: angioplasty and stenting of the carotid artery (via a transfemoral or transcarotid approach)
    • Advantages: an alternative to surgery in patients with poor surgical access or increased risk of perioperative complications [5]
    • Disadvantages: higher risk of periprocedural stroke than CEA
  • Carotid artery bypass grafting: Uncommonly required; may be considered for recurrent or bilateral severe carotid stenosis. [14][19]

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

Recommendations for the screening for asymptomatic carotid stenosis vary. As of 2021, the US Preventive Services Task Force (USPSTF) recommends against screening for asymptomatic individuals, including those with cardiovascular risk factors and carotid bruits. However, other guidelines suggest screening for carotid stenosis in asymptomatic individuals with a carotid bruit and/or risk factors for cardiovascular disease who are potential candidates for carotid intervention.

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  1. Krist AH, Davidson KW, Mangione CM, et al. Screening for Asymptomatic Carotid Artery Stenosis US Preventative Services Task Force Recommendation Statement. JAMA. 2021; 325 (5): p.476. doi: 10.1001/jama.2020.26988 . | Open in Read by QxMD
  2. Kaufman EJ, Mahabadi N, Patel BC. Hollenhorst Plaque. StatPearls. 2020 .
  3. Kleindorfer DO, Towfighi A, Chaturvedi S, et al. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. Stroke. 2021 . doi: 10.1161/str.0000000000000375 . | Open in Read by QxMD
  4. 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
  5. Aboyans V, Ricco J-B, Bartelink M-LEL, et al. 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS). Eur Heart J. 2017; 39 (9): p.763-816. doi: 10.1093/eurheartj/ehx095 . | Open in Read by QxMD
  6. Dorth JA, Patel PR, Broadwater G, Brizel DM. Incidence and risk factors of significant carotid artery stenosis in asymptomatic survivors of head and neck cancer after radiotherapy. Head Neck. 2013; 36 (2): p.215-219. doi: 10.1002/hed.23280 . | Open in Read by QxMD
  7. Blackbourne LH. Surgical Recall. Lippincott Williams & Wilkins ; 2014
  8. Expert Panel on Neurologic Imaging:., Salmela MB, Mortazavi S, et al. ACR Appropriateness Criteria® Cerebrovascular Disease. J Am Coll Radiol. 2017; 14 (5S): p.S34-S61. doi: 10.1016/j.jacr.2017.01.051 . | Open in Read by QxMD
  9. Tahmasebpour HR, Buckley AR, Cooperberg PL, Fix CH. Sonographic Examination of the Carotid Arteries. Radiographics. 2005; 25 (6): p.1561-1575. doi: 10.1148/rg.256045013 . | Open in Read by QxMD
  10. Meschia JF, Bushnell C, Boden-Albala B, et al. Guidelines for the Primary Prevention of Stroke. Stroke. 2014; 45 (12): p.3754-3832. doi: 10.1161/str.0000000000000046 . | Open in Read by QxMD
  11. Catanese L, Tarsia J, Fisher M. Acute Ischemic Stroke Therapy Overview. Circ Res. 2017; 120 (3): p.541-558. doi: 10.1161/circresaha.116.309278 . | Open in Read by QxMD
  12. Nederkoorn PJ, van der Graaf Y, Hunink MGM. Duplex Ultrasound and Magnetic Resonance Angiography Compared With Digital Subtraction Angiography in Carotid Artery Stenosis. Stroke. 2003; 34 (5): p.1324-1331. doi: 10.1161/01.str.0000068367.08991.a2 . | Open in Read by QxMD
  13. Messas E, Goudot G, Halliday A, et al. Management of carotid stenosis for primary and secondary prevention of stroke: state-of-the-art 2020: a critical review. Eur Heart J Suppl. 2020; 22 (Supplement_M): p.M35-M42. doi: 10.1093/eurheartj/suaa162 . | Open in Read by QxMD
  14. Jadhav AP, Ducruet AF, Jankowitz BT, Jovin TG. Management of Bilateral Carotid Occlusive Disease. Interventional Neurology. 2015; 4 (3-4): p.96-103. doi: 10.1159/000442530 . | Open in Read by QxMD
  15. Wabnitz AM, Turan TN. Symptomatic Carotid Artery Stenosis: Surgery, Stenting, or Medical Therapy?. Curr Treat Options Cardiovasc Med. 2017; 19 (8): p.62. doi: 10.1007/s11936-017-0564-0 . | Open in Read by QxMD
  16. Hussain MA, Saposnik G, Raju S, et al. Association Between Statin Use and Cardiovascular Events After Carotid Artery Revascularization. Journal of the American Heart Association. 2018; 7 (16). doi: 10.1161/jaha.118.009745 . | Open in Read by QxMD
  17. Abbott AL, Paraskevas KI, Kakkos SK, et al. Systematic Review of Guidelines for the Management of Asymptomatic and Symptomatic Carotid Stenosis. Stroke. 2015; 46 (11): p.3288-3301. doi: 10.1161/strokeaha.115.003390 . | Open in Read by QxMD
  18. Brott TG, Halperin JL, et al. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease. Stroke. 2011; 42 (8). doi: 10.1161/str.0b013e3182112cc2 . | Open in Read by QxMD
  19. Schermerhorn ML, Liang P, Eldrup-Jorgensen J, et al. Association of Transcarotid Artery Revascularization vs Transfemoral Carotid Artery Stenting With Stroke or Death Among Patients With Carotid Artery Stenosis. JAMA. 2019; 322 (23): p.2313. doi: 10.1001/jama.2019.18441 . | Open in Read by QxMD
  20. Lauder C, Kelly A, Thompson M., London NJ., Bell PR., Naylor A. Early and late outcome after carotid artery bypass grafting with saphenous vein. Journal of Vascular Surgery. 2003; 38 (5): p.1025-1030. doi: 10.1016/s0741-5214(03)00418-x . | Open in Read by QxMD

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