Management of asymptomatic carotid artery stenosis

Carotid artery stenosis is an important risk factor for stroke. However, the majority of patients diagnosed with carotid artery stenosis are asymptomatic. The goal in these patients is to prevent progression of disease and minimize risks for stroke. Despite multiple clinical trials investigating the role medical therapy and interventional techniques, there remain multiple varying opinions on the screening, surveillance, and management strategies for patients with asymptomatic carotid artery stenosis. These differences are in light of continued advancements in therapeutic strategies and treatment modalities. Here we review the current methods for management of patients with asymptomatic carotid artery stenosis. In general all asymptomatic patients should receive aggressive medical management. Patients who are considered higher risk may require additional surveillance and/or intervention. Patients who have a life expectancy of >5 years, and have a stenosis >75%, can benefit from carotid endarterectomy (CEA), but at a small non-negligible risk of perioperative stroke. Patients with difficult anatomy or significant co-morbidites may benefit from carotid artery stenting, but the risk profile with this technique remains higher compared to CEA. Future studies will help further delineate patient populations who may benefit from one treatment strategy versus the other.