Population: Adults with carotid artery disease.
Organizations
AHA/ASA 2014, 2021; SVS 2021
Recommendations
–Prescribe daily aspirin and statin.
–Use antihypertensives to maintain BP < 140/90 for patients with hypertension and asymptomatic extracranial carotid and/or vertebral atherosclerosis.
–If ischemic stroke or TIA and moderate (50%–69%) or severe (≥70%) stenosis, refer for revascularization procedure. (AHA/ASA)
• If severe stenosis, choose carotid artery stenting (CAS) or endarterectomy (CEA), provided perioperative morbidity/mortality risk <6%. If age 70+, consider CEA over CAS. If anatomy increases risk of CEA, choose CAS.
• If moderate stenosis, refer for CEA, provided perioperative morbidity/mortality risk <6%.
–For patients undergoing CAS, use dual antiplatelet therapy (aspirin 81–325 mg daily and clopidogrel 75 mg daily) preprocedure and for a minimum of 30 d after.
–For patients undergoing CEA, use aspirin alone preprocedure and continue indefinitely postoperatively.
Practice Pearl
• Don’t recommend CEA for asymptomatic carotid artery stenosis if the complication risk is >3% (https://www.choosingwisely.org/clinician-lists/american-academy-neurology-cea-for-asymptomatic-carotid-stenosis/).
Sources
–Stroke. 2014;45:3754-3832.
–Stroke. 2021;52:e364-e467.
–J Vasc Surg. 2022;75:4S-22S.