Current state of carotid artery interventions: Clinical trial results and real-world challenges

Carotid artery disease remains a major cause of acute ischemic neurologic syndromes. Contemporary care has evolved into a multi-disciplinary model, involving vascular medicine, neurology, vascular surgery, interventional radiology, interventional cardiology and others. An integrated approach that combines plaque characteristics, symptom timing, cerebral vulnerability, vascular anatomy, patient age and comorbidities is employed to identify optimal treatment strategies. This review focuses on mechanisms of carotid-related stroke, imaging, medical therapy, revascularization of symptomatic and asymptomatic patients and procedural planning. Emphasis is placed on vascular anatomy-driven procedural selection, embolic-risk mitigation, and the complementary roles of carotid endarterectomy, carotid artery stenting, and transcarotid artery revascularization. Optimal outcomes depend less on applying a single preferred revascularization procedure and more on selecting the strategy that most effectively reduces embolic risk and minimizes patient-specific hazards.