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.
- Many patients are asymptomatic.
- Carotid bruit (a pathologic sound heard on auscultation over the carotid artery that is caused by turbulent blood flow)
- Ischemic stroke
- Symptomatic patients
- Noncontrast CT or MRI is indicated for all symptomatic patients with infarctions related to carotid stenosis (see “ for details)
- The immediate diagnosis and management of ischemic symptoms is described in the articles “ ,” ,” and “
- Further work-up with imaging of the carotid artery is indicated in patients with suspected CAS (e.g., carotid bruit, multiple cardiovascular risk factors)
- Asymptomatic patients with a bruit : imaging is indicated to identify a hemodynamically significant carotid stenosis
- Symptomatic patients
Carotid duplex ultrasonography (CDUS)
- Initial test of choice
- Direct visualization of the vessel wall and flow measurement
Magnetic resonance angiography (MRA) or CT angiography (CTA)
- Inconclusive carotid doppler findings
- Evaluation of stenosis severity and planning for revascularization procedures 
- Gold standard for assessing the carotid arteries (i.e., location of stenosis, number of stenoses, plaque morphology, collateral circulation)
- Has been replaced by noninvasive procedures due to high costs and increased risk of neurologic complications.
- Reasonable in patients who cannot undergo CTA/MRA (e.g., renal insufficiency, pacemakers) or in patients with complete carotid artery occlusion to assess whether revascularization is possible
- Medical management: recommended for all patients
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.
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
Embolic protection devices
- Filter devices: fliters dislodged emboli during carotid stent placement without interrupting blood flow
- Retrograde flow devices: temporarily ceases or reverses blood flow; after stent insertion, the proximal internal carotid artery is suctioned prior to the removal of the retrograde flow devices
- Occlussion balloons: inserted into the common carotid artery or external carotid artery via the femoral sheath
- Novel devices: directly placed into the ipsilateral common carotid artery through a small incision at the neck line;
- Transcarotid artery revascularization (TCAR): is a procedure in which a sheath is directly inserted into the carotid artery and gets connected to a system that reverses the direction of blood flow and flters any emboli. The filtered blood returns through a femoral sheath.
- Carotid endarterectomy (CEA): a surgical procedure in which the inner lining of a carotid artery is removed, along with any associated atherosclerotic deposits.
- Carotid artery stenosis is considered an indicator for increased risk of myocardial infarction and cardiovascular death.
- Complications of CEA (during and after the procedure)
We list the most important complications. The selection is not exhaustive.
- Screening for asymptomatic carotid artery stenosis is only recommended in patients with a high risk of stroke (e.g., age > 65 years, coronary artery disease, dyslipidemia, history of tobacco use)
- Noninvasive methods (e.g., duplex ultrasonography, MRA)
- Pre-operative screening