Current role of medical treatment and invasive management in carotid atherosclerotic disease
Poorya Fazel, MD, and Kenneth Johnson, MD
As a significant known risk factor for the development of ischemic stroke, carotid atherosclerosis is a potentially preventable and treatable disease process. The progression of improved diagnostic modalities, including magnetic resonance and computed tomography angiography, has provided enhanced plaque detection and characterization. The management of carotid artery stenosis has also continued to evolve from an aggressive, early surgical approach with the advent of the carotid endarterectomy to the initiation of progressive medical management options and the development of advanced percutaneous intervention. Carotid endarterectomy continues to be the clear treatment of choice in symptomatic patients with >70% carotid stenosis. However, strict risk factor modification, including improved antihypertensive therapy, lipid management, smoking cessation, and antiplatelet therapy, have led to less-compelling indications for immediate surgery in asymptomatic populations. In recent years, the evolution of improved percutaneous techniques and the development and approval of carotid stents have expanded the role of intervention. Several randomized trials have studied the efficacy of carotid artery stenting versus carotid endarterectomy in asymptomatic and symptomatic patients to help define the role of invasive therapy. The primary objective of this review is to summarize the current evidence and standards for the advanced diagnostic and management strategies used in asymptomatic and symptomatic patients with carotid artery stenosis.
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