Patients with Carotid Artery Disease

Carotid artery with plaque build up 

Condition 

Stenoses in the carotid arteries are most commonly
due to atherosclerosis, and these narrowings can lead
to stroke. Stroke is the third leading cause of death in
the United States and the leading cause of permanent
disability. Approximately 25% of all strokes originate
from atherosclerotic plaque at the carotid bifurcation.

The mechanism of stroke from carotid stenosis is most
often an embolic phenomenon and not strictly due to
reduced flow. Multiple acceptable treatment modalities
are available for symptomatic and asymptomatic patients,
and care needs to be personalized with all
options considered.

 

When to Refer 

Any patient with Transient Ischemic Attack (TIA) or stroke of potentially atherosclerotic origin warrants referral to a
vascular surgeon. In addition, the Society for Vascular Surgery (SVS) has developed screening guidelines for patients
at increased risk for asymptomatic carotid stenosis to help identify those who may benefit from prophylactic
intervention to reduce stroke risk.

We recommend screening for carotid disease with duplex ultrasound in any patient with a history of peripheral artery
disease (PAD), regardless of age. People at increased risk for carotid atherosclerosis include individuals over 65 years
of age with coronary artery disease, smoking history, or hypercholesterolemia. The presence of a >50% carotid
stenosis by duplex ultrasound should prompt referral to vascular surgery.

Why to Refer to a Vascular Surgeon

The treatment of carotid atherosclerosis is multi-faceted. Anti-lipid therapy, blood pressure control, lifestyle
modification, and anti-platelet medications are beneficial to all patients with carotid stenosis. For some
asymptomatic patients, the mainstay of treatment is medical therapy, while some patients benefit from
medical therapy and intervention. If your patient would benefit from carotid revascularization to prevent
stroke, vascular surgery is the only discipline trained in all modalities of carotid intervention–
transfemoral stenting (CAS), transcarotid stenting (TCAR) with flow reversal, and carotid
endarterectomy(CEA). Early referral and collaboration with vascular surgery will allow
your patient to be treated with the therapy that is right for them.

Guidelines for Carotid Artery Management*

Screening of Asymptomatic Patients for Carotid Atherosclerosis
is recommended via duplex ultrasound:

In a patient with clinically significant Peripheral Artery Disease (PAD), regardless of age

  • If age > 65 years and has a history of:
    • Smoking
    • Coronary artery disease
    • Hypercholesterolemia
  • Presence of a carotid bruit alone does not warrant screening

Referral to a vascular surgeon is warranted in:

Any patient with a history of transient ischemic attack (TIA) or stroke and > 50% carotid stenosis by
any imaging modality

  • Any asymptomatic patient found to have carotid stenosis of > 50% on screening duplex ultrasound
  • Any patient with non-atherosclerotic disease of the carotid circulation (e.g., carotid body tumor, aneurysm, fibromuscular dysplasia)

Who, When, and How to Treat: 

  • All patients:
    • Smoking cessation
    • Diet modification and lower lipid diet
    • Anti-lipid pharmacotherapy
    • Anti-platelet agents
  • Asymptomatic Patients:
    • With > 60% stenosis on contrast imaging AND acceptable 5-year life expectancy should be considered for intervention by a vascular surgeon
  • Symptomatic patients:
    • With > 50% carotid stenosis should generally undergo intervention by a vascular surgeon
  • The specific method of intervention (CEA, CAS, TCAR) will be recommended by your patient’s vascular surgeon and depends on age, comorbidities, anatomy, risk and your patient’s preference.

*Updated Society for Vascular Surgery guidelines for management of extracranial carotid disease:
https://www.jvascsurg.org/article/S0741-5214%2811%2901635-1/fulltext