Guideline sources The following summarized guidelines for the evaluation and management of carotid artery stenosis (CAS) are prepared by our editorial team based on guidelines from the European Society for Vascular Surgery (ESVS 2023; 2019), the Society for Vascular Surgery (SVS 2022), the European Stroke Organisation (ESO 2021), the European Society of Cardiology (ESC/ESVS 2018), the Society for Cardiovascular Angiography and Interventions (SCAI/SNIS/SVM/AANS/ASNR/CNS/AANN/SVS/AHA/ACR/SAIP/ACC/ASA/SIR 2011), and the U.S. Preventive Services Task Force (USPSTF 2007). 1 2 3 4 5 6 7 8 8 8 9 Definition https://web.pathway.md/diseases/recfWVXAiXmnRM9EH 1/17 6/29/23, 4:04 AM Carotid artery stenosis Pathway CAS refers to a progressive narrowing of the carotid artery. 8 Epidemiology CAS is primarily caused by atherosclerotic vascular disease. 8 Disease course The development of atherosclerotic plaques in the carotid artery is associated with an increased risk of TIA and stroke. 8 Prognosis and risk of recurrence The mortality rate at a mean follow-up of 4 years in adult male patients with high-grade asymptomatic CAS is approximately 37%. 9 Calculator SRU classification of internal car Guidelines 1. Screening and diagnosis Indications for screening, general population: As per ESVS 2023 guidelines: Do not obtain routine screening for asymptomatic CAS in the general population. D Consider obtaining selective screening for asymptomatic CAS to optimize risk factor control and medical therapy in patients with 2 vascular risk factors, mainly aiming to reduce late cardiovascular morbidity and mortality rather than identify candidates for carotid interventions. C As per SVS 2022 guidelines, do not obtain routine screening for clinically asymptomatic CAS in individuals without cerebrovascular symptoms or significant risk factors for carotid artery disease. D Show 2 more As per USPSTF 2007 guidelines, do not obtain screening for asymptomatic CAS in the general adult population. D Indications for screening, before coronary/cardiac interventions: As per ESVS 2023 guidelines: Do not obtain routine screening for carotid disease in patients undergoing open heart surgery. D https://web.pathway.md/diseases/recfWVXAiXmnRM9EH 2/17 6/29/23, 4:04 AM Carotid artery stenosis Pathway Consider obtaining screening for carotid disease with duplex ultrasound in patients undergoing CABG in the following situations allowing patients to be better informed of the increased risks associated with coronary artery bypass in case of concurrent carotid disease: aged > 70 years history of TIA or stroke carotid bruit or left mainstem disease. C As per ESVS/ESC 2018 guidelines, obtain duplex ultrasound in patients undergoing CABG and a recent (< 6 months) TIA/stroke. B Show 3 more Indications for screening (before AAA repair): do not obtain routine screening for asymptomatic CAS before AAA repair. D 2. Diagnostic investigations Carotid artery imaging: As per ESVS 2023 guidelines, obtain duplex ultrasound, computed tomographic angiography and/or MRA in patients undergoing evaluation of the extent and severity of extracranial CAS. B Show 3 more As per ESC 2018 guidelines, obtain duplex ultrasound as first-line imaging modality, CT angiography and/or MRA to evaluate the extent and severity of extracranial CAS. B Show 2 more As per AHA 2011 guidelines, obtain duplex ultrasound, performed by a qualified technologist in a certified laboratory, as the initial diagnostic test to detect hemodynamically significant CAS in asymptomatic patients with known or suspected CAS. B Show 11 more Cranial artery imaging: consider obtaining CT angiography, MRA, or selective cerebral angiography to look for intracranial vascular disease when an extracranial source of ischemia is not identified in patients with transient retinal or hemispheric neurological symptoms of suspected ischemic origin. C Vertebral artery imaging: obtain noninvasive imaging to detect vertebral artery obstructive disease in patients with asymptomatic bilateral carotid occlusions or unilateral carotid artery occlusion and incomplete circle of Willis. B Coronary artery imaging: obtain preoperative screening for coronary artery disease, including coronary angiography, in patients undergoing elective carotid endarterectomy. B 3. Diagnostic procedures Catheter-based contrast angiography: https://web.pathway.md/diseases/recfWVXAiXmnRM9EH 3/17 6/29/23, 4:04 AM Carotid artery stenosis Pathway As per ESVS 2023 guidelines, do not obtain intra-arterial digital subtraction angiography in patients with atherosclerotic disease being candidates for revascularization unless there are significant discrepancies on noninvasive imaging. D As per AHA 2011 guidelines, consider performing catheter-based contrast angiography to detect and characterize extracranial and/or intracranial cerebrovascular disease when noninvasive imaging is inconclusive or not possible due to technical limitations or contraindications in patients with transient retinal or hemispheric neurological symptoms of suspected ischemic origin, or when noninvasive imaging studies yield contradictory results. C Show 2 more 4. Medical management General principles: ensure multidisciplinary team review to reach consensus decisions regarding the indications for carotid endarterectomy, carotid artery stenting, or optimal medical therapy in patients with CAS. B Antiplatelet therapy: As per ESVS 2023 guidelines, consider initiating low-dose aspirin (75-325 mg daily) in patients with > 50% asymptomatic CAS mainly for the prevention of late myocardial infarction and other cardiovascular events. C Show 4 more As per ESC 2018 guidelines: Initiate long-term single antiplatelet therapy in patients with symptomatic CAS. A Consider initiating long-term antiplatelet therapy (commonly low-dose aspirin) in patients with asymptomatic > 50% CAS, if the bleeding risk is low. C As per AHA 2011 guidelines, initiate antiplatelet agents rather than OACs in patients with atherosclerosis of the extracranial carotid artery with B or without ischemic symptoms. B Show 4 more Anticoagulant therapy: As per ESVS 2023 guidelines, initiate therapeutic anticoagulation in patients presenting with recent carotid territory symptoms and evidence of free-floating thrombus within the carotid artery. B As per AHA 2011 guidelines: Consider initiating a vitamin K antagonist (such as warfarin, dose adjusted to achieve a target INR of 2.5) for the prevention of thromboembolic ischemic events in patients with extracranial cerebrovascular atherosclerosis having an indication for anticoagulation, such as AF or a mechanical prosthetic heart valve. C Do not administer full-intensity parenteral anticoagulation with UFH or LMWHoids in patients with extracranial cerebrovascular atherosclerosis developing transient cerebral ischemia or acute ischemic stroke. D https://web.pathway.md/diseases/recfWVXAiXmnRM9EH 4/17 6/29/23, 4:04 AM Carotid artery stenosis Pathway Intravenous thrombolysis: do not administer IV thrombolysis in patients presenting with recent carotid territory symptoms and evidence of free-floating thrombus. D Show 2 more Management of hypertension: As per ESVS 2023 guidelines, initiate antihypertensive therapy in patients with asymptomatic or symptomatic CAS and hypertension. A As per ESC 2018 guidelines: Target controlling BP at < 140/90 mmHg in patients with PAD and hypertension. A Consider offering ACEIs or ARBs as first-line therapy in patients with PAD and hypertension. C As per AHA 2011 guidelines, initiate antihypertensive therapy in patients with hypertension and asymptomatic extracranial carotid artery atherosclerosis to maintain BP < 140/90 mmHg. A Show 2 more Management of dyslipidemia: As per ESVS 2023 guidelines, initiate lipid-lowering therapy with statins (with or without ezetimibe) for the long-term prevention of stroke, myocardial infarction, and other cardiovascular events in patients with asymptomatic CAS. B Show 4 more As per AHA 2011 guidelines, initiate statin therapy in all patients with extracranial carotid artery atherosclerosis to reduce LDL cholesterol to < 100 mg/dL. B Show 5 more Management of diabetes mellitus: As per ESVS 2023 guidelines, ensure optimal glycemic control in patients with diabetes and asymptomatic CAS. B As per ESC 2018 guidelines, obtain strict glycemic control in patients with diabetes mellitus and PAD. B As per AHA 2011 guidelines, consider offering dietary modifications, exercise, and glucose- lowering therapy in patients with diabetes mellitus and extracranial carotid artery atherosclerosis. Insufficient evidence to support the use of intensive glucose-lowering therapy to a HbA1c level < 7.0%. B 5. Nonpharmacologic interventions Lifestyle modifications: As per ESVS 2023 guidelines, provide behavioral counseling to promote a healthy diet, smoking cessation, and physical activity in patients with asymptomatic or symptomatic CAS. B As per ESC 2018 guidelines, advise smoking cessation B , healthy diet and physical activity in all patients with PADs. B https://web.pathway.md/diseases/recfWVXAiXmnRM9EH 5/17 6/29/23, 4:04 AM Carotid artery stenosis Pathway As per AHA 2011 guidelines, advise patients with extracranial carotid artery atherosclerosis to quit smoking, if applicable, and offer smoking cessation interventions to reduce the risks of atherosclerosis progression and stroke. B 6. Therapeutic procedures Mechanical thrombectomy: Consider performing surgical or endovascular removal of the thrombus in patients presenting with recent carotid territory symptoms and free-floating thrombus developing recurrent symptoms whilst receiving anticoagulation therapy. C Consider performing synchronous carotid artery stenting in the presence of poor antegrade internal carotid artery flow or poor collateralization via the circle of Willis after mechanical thrombectomy in patients with acute ischemic stroke undergoing intracranial mechanical thrombectomy with a tandem 50-99% CAS and a small area of ipsilateral infarction. C Carotid artery stenting, asymptomatic patients: As per ESVS 2023 guidelines, consider performing carotid artery stenting as an alternative to carotid endarterectomy in average surgical risk patients with an asymptomatic 60-99% stenosis in the presence of 1 imaging or clinical characteristics associated with an increased risk of late stroke, provided the 30-day stroke/death rate is < 3% and the life expectancy is > 5 years. C Show 2 more As per ESO 2021 guidelines, do not perform carotid stenting as a routine alternative to best medical therapy alone in patients with asymptomatic CAS. D As per ESVS/ESC 2018 guidelines, consider performing carotid artery stenting in asymptomatic patients with a high risk for carotid endarterectomy and an asymptomatic 60-99% stenosis in the presence of clinical and/or imaging characteristics possibly associated with an increased risk of late ipsilateral stroke, provided documented perioperative stroke/death rates are < 3% and the patient's life expectancy is > 5 years. C Show 2 more As per SVS/SVM/SNIS/SIR/SCAI/SAIP/CNS/ASNR/ACR/AANS/AANN/AHA/ACC/ASA 2011 guidelines, obtain assessment of comorbid conditions, life expectancy, and other individual factors and include a thorough discussion of the risks and benefits of the procedure with an understanding of patient preferences to guide the selection of asymptomatic patients for carotid revascularization. B Show 2 more Carotid artery stenting, symptomatic patients: As per ESVS 2023 guidelines, consider performing carotid artery stenting as an alternative to endarterectomy in < 70 years old patients experienced a carotid territory TIA or ischemic stroke within the preceding 6 months in association with a 50-99% CAS, provided the documented 30- day risk of death/stroke is < 6%. B Show 6 more https://web.pathway.md/diseases/recfWVXAiXmnRM9EH 6/17 6/29/23, 4:04 AM Carotid artery stenosis Pathway As per ESO 2021 guidelines, consider performing carotid stenting as an alternative to endarterectomy in < 70 years old patients with symptomatic CAS requiring revascularization. C As per SVS/SVM/SNIS/SIR/SCAI/SAIP/CNS/ASNR/ACR/AANS/AANN/AHA/ACC/ASA 2011 guidelines, perform carotid artery stenting as an alternative to carotid endarterectomy in symptomatic patients at average or low risk of complications associated with endovascular intervention when the diameter of the lumen of the internal carotid artery is reduced by > 70% as documented by noninvasive imaging or > 50% as documented by catheter angiography and the anticipated rate of periprocedural stroke or mortality is < 6%. B Show 5 more Landmark trials: CREST In patients with symptomatic or asymptomatic carotid stenosis, carotid artery stenting was not superior to carotid endarterectomy with respect to stroke, myocardial infarction, or death from any cause during the periprocedural period, or any ipsilateral stroke at 4 years. Brott TG et al. N Engl J Med. 2010 Jul 1. Timing of revascularization: As per ESVS 2023 guidelines, perform carotid intervention, if a carotid intervention is considered appropriate, as soon as possible preferably within 14 days of symptom onset in symptomatic patients with a 50-99% stenosis. A Show 3 more As per SVS 2022 guidelines: Perform carotid revascularization in symptomatic patients with > 50% stenosis and a recent stable stroke (modified Rankin 0-2) as soon as the patient is neurologically stable after 48 hours but definitely before 14 days of onset of symptoms. B Do not perform revascularization regardless of the extent of stenosis in patients suffered a disabling stroke, having a modified Rankin score 3 with an area of infarction > 30% of the ipsilateral middle cerebral artery territory or in patients with altered consciousness to minimize the risk of postoperative parenchymal hemorrhage. Consider reevaluating these patients for revascularization later if neurologic recovery is satisfactory. D As per AHA 2011 guidelines, consider performing carotid artery intervention, if indicated, within 2 weeks of the first cerebral ischemic event (TIA or stroke) rather than delaying surgery, if there are no contraindications to early revascularization. C Technical considerations for stenting (premedication): administer IV atropine or glycopyrrolate before balloon inflation to prevent hypotension, bradycardia, or asystole in patients undergoing carotid artery stenting. B Technical considerations for stenting (arterial approach): consider performing transradial or transcarotid artery revascularization as an alternative to transfemoral carotid artery stenting, especially where transfemoral access may confer a higher risk of complications. C https://web.pathway.md/diseases/recfWVXAiXmnRM9EH 7/17 6/29/23, 4:04 AM Carotid artery stenosis Pathway Technical considerations for stenting (choice of stent): Decide regarding the stent design (open or closed cell) at the discretion of the operator. B Consider using dual-layer mesh-covered stents in patients undergoing elective carotid artery stenting. C Technical considerations for stenting (pre- and post-dilatation): Consider using balloon diameters < 5 mm, if pre-dilatation is planned, to reduce the risk of periprocedural stroke or TIA in patients undergoing carotid artery stenting. C Do not perform post-dilation when the residual stenosis is < 30% in order to reduce hemodynamic instability in patients undergoing carotid artery stenting. D Technical considerations for stenting (cerebral protection): consider using cerebral protection systems in patients undergoing carotid artery stenting. C Show 2 more 7. Perioperative care Perioperative antiplatelet therapy, carotid artery stenting: As per ESVS 2023 guidelines, initiate combination antiplatelet therapy with aspirin (75-325 mg daily) and clopidogrel (75 mg daily) in asymptomatic patients with CAS undergoing carotid artery stenting. Start clopidogrel (75 mg daily) at least 3 days before stenting or as a single 300 mg loading dose given in urgent cases. Continue aspirin and clopidogrel for at least 4 weeks after stenting and then continue antiplatelet monotherapy indefinitely. B Show 2 more As per ESVS/ESC 2018 guidelines, administer dual antiplatelet therapy with aspirin and clopidogrel for at least 1 month after carotid artery stenting. B As per SVS/SVM/SNIS/SIR/SCAI/SAIP/CNS/ASNR/ACR/AANS/AANN/AHA/ACC/ASA 2011 guidelines, administer dual-antiplatelet therapy with aspirin (81-325 mg daily) plus clopidogrel (75 mg daily) before and for a minimum of 30 days after carotid artery stenting. Consider administering ticlopidine (250 mg BID) in patients intolerant of clopidogrel. B Perioperative antiplatelet therapy, carotid endarterectomy: As per ESVS 2023 guidelines, initiate low-dose aspirin (75-325 mg daily) in patients with asymptomatic CAS undergoing carotid endarterectomy. B Show 5 more As per SVS/SVM/SNIS/SIR/SCAI/SAIP/CNS/ASNR/ACR/AANS/AANN/AHA/ACC/ASA 2011 guidelines: Initiate aspirin (81-325 mg daily) before carotid endarterectomy and consider continuing indefinitely postoperatively. A Initiate aspirin (75-325 mg daily), clopidogrel (75 mg daily), or the combination of low-dose aspirin plus ER dipyridamole (25 and 200 mg BID, respectively) for long-term prophylaxis against ischemic cardiovascular events beyond the first month after carotid endarterectomy. B https://web.pathway.md/diseases/recfWVXAiXmnRM9EH 8/17 6/29/23, 4:04 AM Carotid artery stenosis Pathway Perioperative antihypertensive therapy: treat uncontrolled hypertension (> 180/90 mmHg) in patients with symptomatic CAS awaiting endarterectomy or stenting. Be cautious when rapidly lowering BP in the early time period after the onset of symptoms. B Show 2 more Perioperative statin therapy: initiate statin therapy preoperatively in patients scheduled to undergo endarterectomy or stenting. A Perioperative neurological assessment: obtain independent neurological assessment before and after carotid interventions to monitor periprocedural risks. B Management of perioperative hemodynamic instability: consider administering IV crystalloids and volume expanders as first-line therapy in patients with post-carotid hypotension. Consider administering titrated IV vasopressors to maintain systolic BP > 90 mmHg if fluid resuscitation fails to improve BP. C Show 3 more Management of perioperative stroke: differentiate between intra- and postoperative stroke in patients with perioperative stroke. B Show 2 more Management of postoperative neck hematoma: perform immediate re-exploration in patients developing postoperative neck hematoma associated with stridor or tracheal deviation. B 8. Surgical interventions Carotid endarterectomy, asymptomatic patients: As per ESVS 2023 guidelines, consider performing carotid endarterectomy in average surgical risk patients with an asymptomatic 60-99% stenosis in the presence of 1 imaging or clinical characteristics associated with an increased risk of late stroke, provided the 30-day stroke/death rate is < 3% and the life expectancy > is 5 years. C As per SVS 2022 guidelines, perform carotid endarterectomy with best medical therapy over maximal medical therapy alone in patients with a low surgical risk, asymptomatic carotid bifurcation atherosclerosis and a stenosis of > 70% (documented by validated duplex ultrasound or CT angiography/angiography) for the long-term prevention of stroke and death. B As per ESO 2021 guidelines: Perform carotid endarterectomy in asymptomatic patients with 60% CAS deemed to be at increased risk of stroke on best medical therapy alone. B Consider performing endarterectomy as first-line therapy in asymptomatic patients with carotid stenosis, if revascularization is considered appropriate. C As per ESVS/ESC 2018 guidelines, consider performing carotid endarterectomy in patients with an average surgical risk and an asymptomatic 60-99% stenosis in the presence of clinical and/or more imaging characteristics possibly associated with an increased risk of late ipsilateral stroke, provided documented perioperative stroke/death rates are < 3% and the patient's life expectancy is > 5 years. C https://web.pathway.md/diseases/recfWVXAiXmnRM9EH 9/17 6/29/23, 4:04 AM Carotid artery stenosis Pathway As per SVS/SVM/SNIS/SIR/SCAI/SAIP/CNS/ASNR/ACR/AANS/AANN/AHA/ACC/ASA 2011 guidelines, obtain assessment of comorbid conditions, life expectancy, and other individual factors and include a thorough discussion of the risks and benefits of the procedure with an understanding of patient preferences to guide the selection of asymptomatic patients for carotid revascularization. B Show 2 more Carotid endarterectomy, symptomatic patients: As per ESVS 2023 guidelines, consider performing urgent carotid endarterectomy, preferably within 24 hours, in patients with 50-99% stenoses presenting with stroke in evolution or crescendo TIAs. C Show 6 more As per SVS 2022 guidelines: Perform carotid endarterectomy over trans-femoral carotid artery stenting in low/standard risk patients with > 50% symptomatic CAS. B Perform carotid endarterectomy over carotid artery stenting in patients undergoing revascularization within the first 14 days after onset of symptoms. B As per ESO 2021 guidelines, perform carotid endarterectomy in symptomatic patients with severe (70-99%) CAS. A Show 4 more As per SVS/SVM/SNIS/SIR/SCAI/SAIP/CNS/ASNR/ACR/AANS/AANN/AHA/ACC/ASA 2011 guidelines, perform carotid endarterectomy in symptomatic patients at average or low surgical risk experiencing nondisabling ischemic stroke or transient cerebral ischemic symptoms, including hemispheric events or amaurosis fugax, within 6 months if the diameter of the lumen of the ipsilateral internal carotid artery is reduced > 70% as documented by noninvasive imaging and the anticipated rate of perioperative stroke or mortality is < 6%. A Show 7 more Technical considerations for endarterectomy (anesthesia): decide on the choice of anesthesia (locoregional or general) at the discretion of the surgeon/anesthetist performing the procedure, taking into account the local experience, patient preference, and preferred antiplatelet strategy. B Technical considerations for endarterectomy (heparin reversal): consider administering protamine reversal of heparin in patients undergoing carotid endarterectomy. C Technical considerations for endarterectomy (carotid exposure): decide regarding the carotid exposure (antegrade or retrojugular) at the discretion of the operating surgeon. B Technical considerations for endarterectomy (carotid sinus nerve block): do not perform routine carotid sinus nerve blockade in patients undergoing carotid endarterectomy. D Technical considerations for endarterectomy (shunting): consider deciding on performing shunting (routine, selective, never) at the discretion of the operating surgeon. C Technical considerations for endarterectomy (high ICA lesions): anticipate the presence of distal disease extension preoperatively and plan for this in advance. B https://web.pathway.md/diseases/recfWVXAiXmnRM9EH 10/17 6/29/23, 4:04 AM Carotid artery stenosis Pathway Technical considerations for endarterectomy (closure): perform eversion endarterectomy or patched endarterectomy over routine primary arteriotomy closure in patients undergoing carotid endarterectomy. A Show 3 more Technical considerations for endarterectomy (wound drainage): consider performing selective wound drainage in patients undergoing carotid endarterectomy. C Technical considerations for endarterectomy (completion imaging): consider obtaining intraoperative imaging with angiography, duplex ultrasound, or angioscopy to reduce the risk of perioperative stroke in patients undergoing carotid endarterectomy. C Extracranial-to-intracranial carotid bypass: do not perform extracranial-to-intracranial bypass surgery in recently symptomatic patients with extracranial atherosclerotic internal carotid artery occlusion. D 9. Specific circumstances Patients with atrial fibrillation: Obtain a comprehensive neurovascular workup with a multidisciplinary team review to decide between urgent carotid revascularization and anticoagulation alone in patients with a TIA or minor ischemic stroke in the presence of newly diagnosed or known AF and an ipsilateral 50- 99% CAS. B Perform carotid endarterectomy or carotid artery stenting in patients started on anticoagulation (on the basis that cardiac embolism was considered the most likely cause of their TIA or stroke) but having recurrent events in the territory ipsilateral to a 50-99% CAS whilst on therapeutic levels of anticoagulation. B Patients with carotid artery coils and kinks: Do not perform surgical correction of isolated coils/kinks of the internal carotid artery in asymptomatic patients. D Consider performing surgical correction of isolated coils/kinks in symptomatic patients only following multidisciplinary team review and provided no other cause for TIA or stroke symptoms can be identified. C Patients with carotid webs: consider performing carotid endarterectomy or carotid artery stenting to prevent recurrent stroke in recently symptomatic patients with a carotid web if no other cause for stroke can be identified after a detailed neurovascular workup. C Patients with ocular ischemia syndrome: consider performing carotid endarterectomy or carotid artery stenting to prevent further ischemia-induced retinal neovascularization in patients with confirmed ocular ischemia syndrome and a 50-99% ipsilateral CAS. C Patients with common carotid/innominate artery disease: Do not perform open or endovascular interventions in asymptomatic patients with proximal common carotid artery or innominate artery stenoses/occlusions. D https://web.pathway.md/diseases/recfWVXAiXmnRM9EH 11/17 6/29/23, 4:04 AM Carotid artery stenosis Pathway Consider performing open retrograde angioplasty and stenting in symptomatic patients with proximal common carotid artery or innominate stenoses. C Patients with vertebral artery stenosis: do not perform synchronous carotid and vertebral artery revascularizations in patients with combined carotid and vertebral artery disease. D Patients with coronary artery disease: As per ESVS 2023 guidelines, do not perform a staged or synchronous carotid intervention for the prevention of postoperative stroke in patients after coronary artery bypass with an asymptomatic unilateral 70-99% CAS. D Show 4 more As per SVS 2022 guidelines, consider performing carotid endarterectomy before or concomitant with CABG to potentially reduce the risk of stroke and stroke/death in patients with symptomatic CAS 50-99% requiring both carotid endarterectomy and CABG. Decide on the sequencing of the intervention based on clinical presentation and institutional experience. C Show 2 more As per AHA 2011 guidelines: Consider performing carotid revascularization by carotid endarterectomy or carotid artery stenting with embolic protection before or concurrent with myocardial revascularization surgery in patients with > 80% CAS experienced ipsilateral retinal or hemispheric cerebral ischemic symptoms within 6 months. C Recognize that the safety and effectiveness of carotid revascularization before or concurrent with myocardial revascularization are not well established in patients with asymptomatic CAS, even if severe. B Patients with abdominal aortic aneurysm: Consider performing carotid artery intervention before aneurysm repair in patients with AAA and concomitant symptomatic CAS within the last 6 months. B Do not perform routine prophylactic carotid intervention for asymptomatic CAS before AAA repair. D Patients undergoing non-cardiac surgery (preoperative evaluation): do not obtain routine carotid imaging in asymptomatic patients undergoing non-cardiac surgical procedures. D Show 2 more Patients undergoing non-cardiac surgery (timing): delay elective non-cardiac surgery by 6 months where possible in patients with a history of stroke and no significant carotid artery disease. Individualize the decision on proceeding with semi-urgent elective surgery based on the underlying pathology. B Patients undergoing non-cardiac surgery (preoperative statins and antithrombotics): do not discontinue statin therapy before surgery in patients with asymptomatic 50-99% carotid artery stenoses undergoing a major non-cardiac procedure. Withhold antithrombotic therapy based on an assessment of thromboembolic and hemorrhagic risks. D Patients undergoing non-cardiac surgery (carotid revascularization): https://web.pathway.md/diseases/recfWVXAiXmnRM9EH 12/17 6/29/23, 4:04 AM Carotid artery stenosis Pathway Do not perform prophylactic carotid endarterectomy or carotid artery stenting in patients with an asymptomatic 50-99% CAS undergoing major non-cardiac surgery. D Consider performing carotid revascularization before the non-cardiac surgical procedure in patients with a history of stroke or TIA in the preceding 6 months attributable to an ipsilateral 50- 99% CAS and scheduled to undergo elective non-cardiac surgery. B 10. Follow-up and surveillance Follow-up imaging (medically treated patients): consider obtaining repeated duplex ultrasound annually by a qualified technologist in a certified laboratory to assess the progression or regression of disease and response to therapeutic interventions in patients with atherosclerosis who have had stenosis > 50% detected previously. C Show 2 more Follow-up imaging (after revascularization): consider obtaining noninvasive imaging of the extracranial carotid arteries 1 month, 6 months, and annually after revascularization to assess patency and exclude the development of new or contralateral lesions. C Show 2 more Management of recurrent carotid stenosis: As per ESVS 2023 guidelines, perform re-do carotid endarterectomy or carotid artery stenting in patients experiencing a late ipsilateral stroke or TIA in the presence of an ipsilateral 50-99% restenosis. B Show 6 more As per ASA 2011 guidelines, consider performing repeated carotid endarterectomy or carotid artery stenting using the same criteria as recommended for initial revascularization in patients with symptomatic cerebral ischemia and recurrent CAS due to intimal hyperplasia or atherosclerosis. C Show 3 more Management of carotid patch/stent infection: perform excision and autologous venous reconstruction in patients with prosthetic patch infection or carotid stent infection. B Show 2 more 11. Quality improvement Hospital requirements: As per ESVS 2023 guidelines, consider ensuring at least 12 carotid stent procedures per year (per operator) as an appropriate operator volume threshold in order to maintain optimal outcomes in patients undergoing transfemoral carotid artery stenting. C Show 3 more As per ESC 2018 guidelines, healthcare centers should set up a multidisciplinary vascular team to make decisions for the management of patients with PADs. B https://web.pathway.md/diseases/recfWVXAiXmnRM9EH 13/17 6/29/23, 4:04 AM Carotid artery stenosis Pathway Public health measures: implement and support initiatives to improve medical and public awareness of PADs, especially cerebrovascular and lower extremity artery diseases. B Clinical findings Patient demographics Symptoms Age > 60 Dizziness Facial weakness Past medical history Headache Limb numbness Aortic aneurysm Loss of balance Atherosclerotic disease Visual disturbances Coronary artery disease Weakness of limb Diabetes mellitus Dyslipidemia Social history Hypercholesterolemia Limb-shaking TIA Current cigarette smoking Obesity Vascular exam PAD Sleep apnea Carotid bruit Stroke Ocular exam TIA Amaurosis fugax Vital signs Retinal infarction Hypertension Neurological exam Dysarthria Expressive aphasia Facial nerve palsy Homonymous hemianopsia Receptive aphasia Visuospatial neglect Imaging findings Carotid artery occlusion Likelihood Ratios Pertinent positives The following findings increase the probability of carotid artery stenosis in adults. 9 10 https://web.pathway.md/diseases/recfWVXAiXmnRM9EH 14/17 6/29/23, 4:04 AM Carotid artery stenosis Pathway Finding LR+ Value Presence of carotid bruit and CNS symptoms 3.0 (1.3-7.1) Presence of carotid bruit 1.6 Pertinent negatives The following findings decrease the probability of carotid artery stenosis in adults. 9 10 Finding LR- Value Absence of carotid bruit and CNS symptoms 0.49 (0.36-0.67) Absence of carotid bruit 0.6 Studies 2018 DEFUSE 3 In patients 6 to 16 hours after they were last known to be well and who had remaining ischemic brain tissue that was not yet infarcted, endovascular therapy was superior to medical therapy with respect to median score on mRS at 90 days. Gregory W Albers et al. N Engl J Med. 2018 Feb 22. 2018 DAWN In patients with occlusion of the intracranial internal carotid artery or proximal middle cerebral artery who had last been known to be well 6 to 24 hours earlier and who had a mismatch between the severity of the clinical deficit and the infarct volume, thrombectomy was superior to control with respect to score on utility-weighted mRS at 90 days. Raul G Nogueira et al. N Engl J Med. 2018 Jan 4. Show 3 more References 1. Leo H Bonati, Stavros Kakkos, Joachim Berkefeld et al. European Stroke Organisation guideline on endarterectomy and stenting for carotid artery stenosis. Eur Stroke J. 2021 Jun;6 2 I XLVII. Open 2. Victor Aboyans, Jean-Baptiste Ricco, Marie-Louise E L Bartelink et al. 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery ESVS Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteriesEndorsed by: the European Stroke Organization ESO The Task Force for the Diagnosis and Treatment of Peripheral Arterial Diseases of the European Society of Cardiology ESC and of the European Society for Vascular Surgery ESVS . Eur Heart J. 2018 Mar 1;39 9 763 816. Open 3. Ross Naylor, Barbara Rantner, Stefano Ancetti et al. Editor's Choice European Society for Vascular Surgery ESVS 2023 Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease. Eur J Vasc Endovasc Surg. 2023 Jan;65 1 7 111. 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