Carotid Revascularization Protocol for Symptomatic Stenosis

Carotid endarterectomy (CEA) has been considered the standard of care for symptomatic carotid stenosis (sCS). Carotid artery stenting (CAS) warrants reevaluation for equivalence to CEA given advances in embolic protection and stent technology. Our patients with sCS undergo computed tomography angiography and perfusion, magnetic resonance imaging, and carotid duplex ultrasonography to guide selection for CEA, CAS, or transcarotid artery revascularization (TCAR). Preoperative management includes dual antiplatelet therapy and maximal-dose statin therapy, comorbidity optimization, smoking cessation counseling, cardiac risk assessment for stroke, systemic anticoagulation for an intraluminal thrombus, and perfusion-based risk stratification. For CAS, we routinely use dual embolic protection with proximal balloon occlusion and distal filters, second-generation micromesh stents, and poststenting aspiration. Intravascular lithotripsy and integrated embolic protection have broadened the indications for CAS. We present our algorithm for managing sCS, demonstrating CEA, CAS, and TCAR as equivalent in safety and effectiveness for most patients, while recognizing select factors conferring higher risk with each approach.