Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

asymptomatic carotid stenosis <70%

1st line – antiplatelet therapy and cardiovascular risk reduction

Back
ACUTE
|
asymptomatic carotid stenosis <70%
1st line – 

antiplatelet therapy and cardiovascular risk reduction

Antiplatelet therapy should be started preoperatively to reduce the risk of complications such as stroke and myocardial infarction. It should be initiated at diagnosis and continued indefinitely after the procedure.

In asymptomatic patients, aspirin is the preferred medication because of its known benefits in preventing myocardial infarction in vascular patients. In the presence of a contraindication to aspirin, clopidogrel is a reasonable alternative; other antiplatelet agents (e.g., dipyridamole) may be considered if neither aspirin or clopidogrel can be used, depending on availability.[2]​ 

Patients on anticoagulation (e.g., warfarin) for an unrelated indication should not be given antiplatelet agents for carotid stenosis except in special circumstances (e.g., presence of a stent), and should continue on the anticoagulant with the additional goal of preventing atheroembolic stroke.[1]​​[33]

Risk factors such as cigarette smoking, diabetes, and hypertension must be managed according to appropriate guidelines.[1][2]

Lifestyle modifications include adopting a healthy diet and increased physical activity and exercise as appropriate.[1][2]

Primary options

aspirin: 75-325 mg orally once daily

Secondary options

clopidogrel: 75 mg orally once daily

Consider – lipid-lowering therapy

Back
ACUTE
|
asymptomatic carotid stenosis <70%
Consider – 

lipid-lowering therapy

Additional treatment recommended for SOME patients in selected patient group

Lipid-lowering therapy with statins (with or without ezetimibe) is recommended for patients with asymptomatic stenosis for prevention of cardiovascular events.[2]​ Patients undergoing endarterectomy or stenting should start or continue statin therapy prior to the procedure; statins should not be stopped during the perioperative period, and should be continued long term if tolerated.[2] Statins have a particularly important role in treating carotid stenosis and patients should be encouraged to persist with these medications. 

Addition of ezetimibe is recommended for those who do not reach lipid targets despite maximum tolerated dose of statin. Additional or alternative treatment with proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors (monoclonal antibodies) should be considered for those patients who do not reach lipid targets despite maximum tolerated dose of statin and ezetimibe, or who are intolerant.[2] 

Primary options

atorvastatin: 40-80 mg orally once daily

OR

rosuvastatin: 20-40 mg orally once daily

Secondary options

atorvastatin: 40-80 mg orally once daily

or

rosuvastatin: 20-40 mg orally once daily

-- AND --

ezetimibe: 10 mg orally once daily

OR

atorvastatin: 40-80 mg orally once daily

or

rosuvastatin: 20-40 mg orally once daily

-- AND --

ezetimibe: 10 mg orally once daily

-- AND --

alirocumab: 75-150 mg subcutaneously every 2 weeks; or 300 mg subcutaneously every 4 weeks

or

evolocumab: 140 mg subcutaneously every 2 weeks; or 420 mg subcutaneously once monthly

OR

alirocumab: 75-150 mg subcutaneously every 2 weeks; or 300 mg subcutaneously every 4 weeks

OR

evolocumab: 140 mg subcutaneously every 2 weeks; or 420 mg subcutaneously once monthly

Consider – carotid endarterectomy (very rarely needed)

Back
ACUTE
|
asymptomatic carotid stenosis <70%
Consider – 

carotid endarterectomy (very rarely needed)

Additional treatment recommended for SOME patients in selected patient group

Very rarely performed in this patient group.

As plaques within the carotid bulb enlarge and the overlying fibrin cap is eroded, ulcerations may appear over the surface. This becomes a source of atheroemboli to the retina and cerebral cortex. By far the majority of large ulcerations occur in association with high-grade stenoses and will warrant carotid endarterectomy on the basis of the degree of stenosis.

Asymptomatic patients with large ulcers in the presence of <50% stenosis form a therapeutic dilemma. These conditions are possible indications for carotid endarterectomy, but the recommendation is based on weak evidence, and such cases merit careful discussion in a multi-disciplinary team meeting.[2][39]

Asymptomatic carotid stenosis may be addressed after coronary revascularisation. Conversely, patients with symptomatic carotid stenosis and stable coronary disease may have carotid endarterectomy performed 1-4 weeks before coronary bypass.[1] 

Intraoperative anticoagulation with heparin is used to help to prevent stroke as a complication.

asymptomatic carotid stenosis ≥70%: good surgical candidate

1st line – carotid endarterectomy

Back
ACUTE
|
asymptomatic carotid stenosis ≥70%: good surgical candidate
1st line – 

carotid endarterectomy

The selection of asymptomatic patients for carotid revascularisation should be guided by the severity of stenosis, and an assessment of the patient's comorbid conditions, life expectancy, surgeon-specific outcomes, and preferences of the patient concerning intervention.

The 2021 Society for Vascular Surgery guidelines and 2011 multisociety guidelines recommend carotid endarterectomy, in addition to the pharmacological treatment listed, for patients with asymptomatic carotid stenosis ≥70% if the risk of perioperative stroke, myocardial infarction, and death is low.[1][14]​ The 2023 European Society for Vascular Surgery guidelines recommend that carotid endarterectomy should be considered in patients with asymptomatic stenosis ≥60% to 99% and an increased risk of late stroke, provided perioperative stroke/death rates are low (≤3%) and patient life expectancy exceeds 5 years.[2]

Asymptomatic carotid stenosis may be addressed after coronary revascularisation in patients with coronary artery disease.[1]

Intraoperative anticoagulation with heparin is used to help to prevent thrombotic stroke as a complication.

Plus – antiplatelet therapy and cardiovascular risk reduction

Back
ACUTE
|
asymptomatic carotid stenosis ≥70%: good surgical candidate
Plus – 

antiplatelet therapy and cardiovascular risk reduction

Treatment recommended for ALL patients in selected patient group

Antiplatelet therapy should be started preoperatively to reduce the risk of complications such as stroke and myocardial infarction. It should be initiated at diagnosis and continued indefinitely after the procedure. In asymptomatic patients with carotid artery stenosis, aspirin is the preferred medication because of its known benefits in preventing myocardial infarction in vascular patients. In the presence of a contraindication to aspirin, clopidogrel is a reasonable alternative; other antiplatelet agents (e.g., dipyridamole) may be considered if neither aspirin or clopidogrel can be used.[2]

Patients on anticoagulation (e.g., warfarin) for an unrelated indication should not be given antiplatelet agents for carotid stenosis except in special circumstances (e.g., presence of a stent), and should continue on the anticoagulant with the additional goal of preventing atheroembolic stroke.[1]​​[33]

Risk factors such as cigarette smoking, diabetes, and hypertension must be managed according to appropriate guidelines.[1][2]

Lifestyle modifications include adopting a healthy diet and increased physical activity and exercise as appropriate.[1][2]

Primary options

aspirin: 75-325 mg orally once daily

Secondary options

clopidogrel: 75 mg orally once daily

Consider – lipid-lowering therapy

Back
ACUTE
|
asymptomatic carotid stenosis ≥70%: good surgical candidate
Consider – 

lipid-lowering therapy

Additional treatment recommended for SOME patients in selected patient group

Lipid-lowering therapy with statins (with or without ezetimibe) is recommended for patients with asymptomatic stenosis for prevention of cardiovascular events.[2] ​Patients undergoing endarterectomy or stenting should start or continue statin therapy prior to the procedure; statins should not be stopped during the perioperative period, and should be continued long term if tolerated.[2]​ Statins have a particularly important role in treating carotid stenosis and patients should be encouraged to persist with these medications.

Addition of ezetimibe is recommended for those who do not reach lipid targets despite maximum tolerated dose of statin. Additional or alternative treatment with proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors (monoclonal antibodies) should be considered for those patients who do not reach lipid targets despite maximum tolerated dose of statin and ezetimibe, or who are intolerant.[2]​ 

Primary options

atorvastatin: 40-80 mg orally once daily

OR

rosuvastatin: 20-40 mg orally once daily

Secondary options

atorvastatin: 40-80 mg orally once daily

or

rosuvastatin: 20-40 mg orally once daily

-- AND --

ezetimibe: 10 mg orally once daily

OR

atorvastatin: 40-80 mg orally once daily

or

rosuvastatin: 20-40 mg orally once daily

-- AND --

ezetimibe: 10 mg orally once daily

-- AND --

alirocumab: 75-150 mg subcutaneously every 2 weeks; or 300 mg subcutaneously every 4 weeks

or

evolocumab: 140 mg subcutaneously every 2 weeks; or 420 mg subcutaneously once monthly

OR

alirocumab: 75-150 mg subcutaneously every 2 weeks; or 300 mg subcutaneously every 4 weeks

OR

evolocumab: 140 mg subcutaneously every 2 weeks; or 420 mg subcutaneously once monthly

asymptomatic carotid stenosis ≥70%: poor surgical candidate

1st line – carotid artery stenting

Back
ACUTE
|
asymptomatic carotid stenosis ≥70%: poor surgical candidate
1st line – 

carotid artery stenting

It is reasonable to perform carotid artery stenting when revascularisation is indicated in patients who are poor surgical candidates due to neck anatomy unfavourable for surgery (e.g., very high lesion close to the base of the skull, radiation-induced stenosis, tracheostomy, or restenosis after a prior carotid endarterectomy).[1]​ Results from the CREST and ASCT-2 trials and a subsequent meta-analysis have found that both stenting and endarterectomy had a similar low risk of complications and are similarly effective in reducing the risk of disabling stroke.[34][35][37]​

The benefit of this procedure in asymptomatic patients is only derived if they are at low risk for myocardial infarction or death.

This approach may differ in other countries. For example, in the UK stenting is only recommended within randomised controlled trials.[38]

Asymptomatic carotid stenosis may be addressed after coronary revascularisation in patients with coronary artery disease.[1]

Plus – antiplatelet therapy and cardiovascular risk reduction

Back
ACUTE
|
asymptomatic carotid stenosis ≥70%: poor surgical candidate
Plus – 

antiplatelet therapy and cardiovascular risk reduction

Treatment recommended for ALL patients in selected patient group

Antiplatelet therapy should be started preoperatively to reduce the risk of complications such as stroke and myocardial infarction. It should be initiated at diagnosis and continued indefinitely after the procedure. Dual antiplatelet therapy is recommended in patients with stents and is used for at least 4 weeks after stenting, followed by antiplatelet monotherapy.[2] 

Risk factors such as cigarette smoking, diabetes, and hypertension must be managed according to appropriate guidelines.[1][2]

Lifestyle modifications include adopting a healthy diet and increased physical activity and exercise as appropriate.[1][2]

Primary options

aspirin: 75-325 mg orally once daily for at least 4 weeks followed by antiplatelet monotherapy

and

clopidogrel: 75 mg orally once daily for first 1-3 months for at least 4 weeks followed by antiplatelet monotherapy

Consider – lipid-lowering therapy

Back
ACUTE
|
asymptomatic carotid stenosis ≥70%: poor surgical candidate
Consider – 

lipid-lowering therapy

Additional treatment recommended for SOME patients in selected patient group

Lipid-lowering therapy with statins (with or without ezetimibe) is recommended for patients with asymptomatic stenosis for prevention of cardiovascular events.[2] ​Patients undergoing endarterectomy or stenting should start or continue statin therapy prior to the procedure; statins should not be stopped during the perioperative period, and should be continued long term if tolerated.[2]​ Statins have a particularly important role in treating carotid stenosis and patients should be encouraged to persist with these medications.

Addition of ezetimibe is recommended for those who do not reach lipid targets despite maximum tolerated dose of statin. Additional or alternative treatment with proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors (monoclonal antibodies) should be considered for those patients who do not reach lipid targets despite maximum tolerated dose of statin and ezetimibe, or who are intolerant.[2]

Primary options

atorvastatin: 40-80 mg orally once daily

OR

rosuvastatin: 20-40 mg orally once daily

Secondary options

atorvastatin: 40-80 mg orally once daily

or

rosuvastatin: 20-40 mg orally once daily

-- AND --

ezetimibe: 10 mg orally once daily

OR

atorvastatin: 40-80 mg orally once daily

or

rosuvastatin: 20-40 mg orally once daily

-- AND --

ezetimibe: 10 mg orally once daily

-- AND --

alirocumab: 75-150 mg subcutaneously every 2 weeks; or 300 mg subcutaneously every 4 weeks

or

evolocumab: 140 mg subcutaneously every 2 weeks; or 420 mg subcutaneously once monthly

OR

alirocumab: 75-150 mg subcutaneously every 2 weeks; or 300 mg subcutaneously every 4 weeks

OR

evolocumab: 140 mg subcutaneously every 2 weeks; or 420 mg subcutaneously once monthly

symptomatic

1st line – carotid endarterectomy or stenting

Back
ACUTE
|
symptomatic
|
ipsilateral carotid stenosis ≥50%
1st line – 

carotid endarterectomy or stenting

Symptomatic patients include those with transient ischaemic attack, stroke, and transient monocular blindness (amaurosis fugax).

Symptomatic patients should undergo carotid endarterectomy if the carotid stenosis is ≥50% (NASCET criteria).[1][2][14][40]​​​ Rapid referral to a specialist as soon as the neurological event occurs is recommended, with early revascularisation (i.e., within 2 weeks) in patients whose neurological symptoms have stabilised; however, there are no recent trials on this, and the magnitude of benefit of early revascularisation is unclear. 

Concomitant coronary artery disease should be considered. Patients with symptomatic carotid stenosis and stable coronary disease may have carotid endarterectomy performed 1-4 weeks before coronary bypass.[1] The combination of carotid endarterectomy and coronary bypass is associated with a perioperative stroke, myocardial infarction, and death rate of 9% to 12%.[43] Therefore, the combined procedure is only recommended for the rare patient with concurrent symptomatic carotid stenosis and critically symptomatic coronary artery disease.[44]

Carotid stenting is more risky than carotid endarterectomy in older patients, but can be considered as an alternative to surgery in younger patients (65 years or less) in centres where carotid stenting is regularly performed.[2][41][42]​ It is reasonable to perform carotid artery stenting as an alternative to endarterectomy when the patient is considered to be high risk for surgery.[1]​​[2]

Plus – antiplatelet therapy and cardiovascular risk reduction

Back
ACUTE
|
symptomatic
|
ipsilateral carotid stenosis ≥50%
Plus – 

antiplatelet therapy and cardiovascular risk reduction

Treatment recommended for ALL patients in selected patient group

Antiplatelet therapy should be started preoperatively to reduce the risk of complications such as stroke and myocardial infarction. It should be initiated at diagnosis (after imaging has excluded intracranial haemorrhage) and continued indefinitely after the procedure.[2]​

Aspirin alone, clopidogrel alone, or the combination of aspirin plus extended-release dipyridamole are the preferred medications in symptomatic patients undergoing endarterectomy.[1] Antiplatelet therapy is initiated at diagnosis and continued indefinitely after carotid endarterectomy. Dual antiplatelet therapy (e.g., aspirin plus clopidogrel) is preferred in patients with stents and is used for at least 4 weeks after stenting, followed by antiplatelet monotherapy indefinitely.[2]

Risk factors such as cigarette smoking, diabetes, and hypertension must be managed according to appropriate guidelines.[1][2]

Lifestyle modifications include adopting a healthy diet and increased physical activity and exercise as appropriate.[1][2]

Primary options

aspirin: 75-325 mg orally once daily

OR

clopidogrel: 75 mg orally once daily

OR

aspirin/dipyridamole: 25/200 mg orally twice daily

OR

aspirin: 75-325 mg orally once daily for at least 4 weeks followed by antiplatelet monotherapy

and

clopidogrel: 75 mg orally once daily for at least 4 weeks followed by antiplatelet monotherapy

Plus – lipid-lowering therapy

Back
ACUTE
|
symptomatic
|
ipsilateral carotid stenosis ≥50%
Plus – 

lipid-lowering therapy

Treatment recommended for ALL patients in selected patient group

High-intensity statin therapy should be started or re-prescribed preoperatively,​ treating to a target LDL-cholesterol level of <1.8 mmol/L (<70 mg/dL).[2][46][47]​​ Statins have a particularly important role in treating carotid stenosis and patients should be encouraged to persist with these medications. 

Addition of ezetimibe is recommended for those who do not reach lipid targets despite maximum tolerated dose of statin. Additional or alternative treatment with proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors (monoclonal antibodies) should be considered for those patients who do not reach lipid targets despite maximum tolerated dose of statin and ezetimibe, or who are intolerant.[2]

Primary options

atorvastatin: 40-80 mg orally once daily

OR

rosuvastatin: 20-40 mg orally once daily

Secondary options

atorvastatin: 40-80 mg orally once daily

or

rosuvastatin: 20-40 mg orally once daily

-- AND --

ezetimibe: 10 mg orally once daily

OR

atorvastatin: 40-80 mg orally once daily

or

rosuvastatin: 20-40 mg orally once daily

-- AND --

ezetimibe: 10 mg orally once daily

-- AND --

alirocumab: 75-150 mg subcutaneously every 2 weeks; or 300 mg subcutaneously every 4 weeks

or

evolocumab: 140 mg subcutaneously every 2 weeks; or 420 mg subcutaneously once monthly

OR

alirocumab: 75-150 mg subcutaneously every 2 weeks; or 300 mg subcutaneously every 4 weeks

OR

evolocumab: 140 mg subcutaneously every 2 weeks; or 420 mg subcutaneously once monthly

1st line – antiplatelet therapy and cardiovascular risk reduction

Back
ACUTE
|
symptomatic
|
ipsilateral carotid stenosis <50%
1st line – 

antiplatelet therapy and cardiovascular risk reduction

Pharmacotherapy is the treatment of choice in patients with <50% stenosis.

For symptomatic patients not being considered for carotid endarterectomy or stenting, the 2023 European Society for Vascular Surgery guidelines recommend aspirin plus clopidogrel for 21 days followed by clopidogrel monotherapy, or long-term aspirin plus modified-release dipyridamole.[2]​ Other antiplatelet agents (e.g., ticagrelor or dipyridamole) may be considered if neither aspirin or clopidogrel can be used, depending on availability.[2]

Risk factors such as cigarette smoking, diabetes, and hypertension must be managed according to appropriate guidelines.[1][2]

Lifestyle modifications include adopting a healthy diet and increased physical activity and exercise as appropriate.[1][2]

Primary options

aspirin: 75-325 mg orally once daily for 21 days followed by clopidogrel monotherapy

and

clopidogrel: 75 mg orally once daily

OR

aspirin/dipyridamole: 25/200 mg orally twice daily

Plus – lipid-lowering therapy

Back
ACUTE
|
symptomatic
|
ipsilateral carotid stenosis <50%
Plus – 

lipid-lowering therapy

Treatment recommended for ALL patients in selected patient group

High-intensity statin therapy should be started or re-prescribed, treating to a target LDL-cholesterol level of <1.8 mmol/L (<70 mg/dL).[2]​​[46][47]​ Statins have a particularly important role in treating carotid stenosis and patients should be encouraged to persist with these medications. 

Addition of ezetimibe is recommended for those who do not reach lipid targets despite maximum tolerated dose of statin. Additional or alternative treatment with proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors (monoclonal antibodies) should be considered for those patients who do not reach lipid targets despite maximum tolerated dose of statin and ezetimibe, or who are intolerant.[2]

Primary options

atorvastatin: 40-80 mg orally once daily

OR

rosuvastatin: 20-40 mg orally once daily

Secondary options

atorvastatin: 40-80 mg orally once daily

or

rosuvastatin: 20-40 mg orally once daily

-- AND --

ezetimibe: 10 mg orally once daily

OR

atorvastatin: 40-80 mg orally once daily

or

rosuvastatin: 20-40 mg orally once daily

-- AND --

ezetimibe: 10 mg orally once daily

-- AND --

alirocumab: 75-150 mg subcutaneously every 2 weeks; or 300 mg subcutaneously every 4 weeks

or

evolocumab: 140 mg subcutaneously every 2 weeks; or 420 mg subcutaneously once monthly

OR

alirocumab: 75-150 mg subcutaneously every 2 weeks; or 300 mg subcutaneously every 4 weeks

OR

evolocumab: 140 mg subcutaneously every 2 weeks; or 420 mg subcutaneously once monthly

ONGOING

bilateral carotid stenosis

1st line – carotid endarterectomy or stenting based on merits of each carotid artery

Back
ONGOING
|
bilateral carotid stenosis
1st line – 

carotid endarterectomy or stenting based on merits of each carotid artery

In asymptomatic people found to have bilateral carotid stenoses ≥70%, the higher-grade stenosis is generally addressed surgically first. In the case of equal degrees of stenosis, handedness is considered. For example, the left carotid would usually be surgically treated first in a right-handed person.

In symptomatic people (i.e., transient ischaemic attack, amaurosis fugax, or stroke) found to have carotid stenosis in a contralateral carotid artery, the asymptomatic carotid stenosis is treated based on the merits of that stenosis. Generally if surgery is indicated, it might be undertaken electively several weeks after treatment related to the acute neurological episode. This is to allow resolution of and observation of neurological symptoms.

In the case where bilateral carotid endarterectomy is required, the evaluation of cranial nerve function (IX, X, XII) may be indicated prior to the second surgery.

Relationship to any existing coronary artery disease may also need to be considered.

Plus – antiplatelet therapy and cardiovascular risk reduction

Back
ONGOING
|
bilateral carotid stenosis
Plus – 

antiplatelet therapy and cardiovascular risk reduction

Treatment recommended for ALL patients in selected patient group

Antiplatelet therapy should be started preoperatively to reduce the risk of complications such as stroke and myocardial infarction. It should be initiated at diagnosis and continued indefinitely after the procedure. If the patient undergoes endarterectomy, aspirin or clopidogrel monotherapy is recommended. Dual antiplatelet therapy (e.g., aspirin plus clopidogrel) is preferred in patients with stents and is used for at least 4 weeks after stenting, followed by antiplatelet monotherapy indefinitely.[2]​​

Risk factors such as cigarette smoking, diabetes, and hypertension must be managed according to appropriate guidelines.[1][2]

Lifestyle modifications include adopting a healthy diet and increased physical activity and exercise as appropriate.[1][2]

Primary options

aspirin: 75-325 mg orally once daily for at least 4 weeks followed by antiplatelet monotherapy

and

clopidogrel: 75 mg orally once daily for at least 4 weeks followed by antiplatelet monotherapy

Plus – lipid-lowering therapy

Back
ONGOING
|
bilateral carotid stenosis
Plus – 

lipid-lowering therapy

Treatment recommended for ALL patients in selected patient group

High-intensity statin therapy should be started or re-prescribed preoperatively,​ treating to a target LDL-cholesterol level of <1.8 mmol/L (<70 mg/dL).[2]​​[46][47] Statins have a particularly important role in treating carotid stenosis and patients should be encouraged to persist with these medications.

Addition of ezetimibe is recommended for those who do not reach lipid targets despite maximum tolerated dose of statin. Additional or alternative treatment with proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors (monoclonal antibodies) should be considered for those patients who do not reach lipid targets despite maximum tolerated dose of statin and ezetimibe, or who are intolerant.[2]

Primary options

atorvastatin: 40-80 mg orally once daily

OR

rosuvastatin: 20-40 mg orally once daily

Secondary options

atorvastatin: 40-80 mg orally once daily

or

rosuvastatin: 20-40 mg orally once daily

-- AND --

ezetimibe: 10 mg orally once daily

OR

atorvastatin: 40-80 mg orally once daily

or

rosuvastatin: 20-40 mg orally once daily

-- AND --

ezetimibe: 10 mg orally once daily

-- AND --

alirocumab: 75-150 mg subcutaneously every 2 weeks; or 300 mg subcutaneously every 4 weeks

or

evolocumab: 140 mg subcutaneously every 2 weeks; or 420 mg subcutaneously once monthly

OR

alirocumab: 75-150 mg subcutaneously every 2 weeks; or 300 mg subcutaneously every 4 weeks

OR

evolocumab: 140 mg subcutaneously every 2 weeks; or 420 mg subcutaneously once monthly

carotid restenosis

1st line – continued antiplatelet therapy and cardiovascular risk reduction ± revascularisation

Back
ONGOING
|
carotid restenosis
1st line – 

continued antiplatelet therapy and cardiovascular risk reduction ± revascularisation

Recurrent high-grade stenosis after a prior carotid endarterectomy or stenting occurs infrequently (approximately 6% over 2 years).[45]

Restenosis is generally a consequence of neointimal hyperplasia when it occurs within the first 2 years after surgery; and commonly due to new atherosclerotic plaque when it occurs beyond 2 years after surgery.

Residual stenosis is a stenosis found within 30 days of the carotid intervention.

There is ongoing controversy regarding the optimal treatment approach for this relatively rare occurrence.[2][45]​​​​ In many countries, medical management (i.e., aspirin, clopidogrel, or ticlopidine monotherapy) is recommended in asymptomatic patients owing to the low risk of embolic stroke associated with neointimal hyperplasia. Revascularisation is reserved for symptomatic patients, and rarely for the infrequent cases of rapid progression. The method of revascularisation is not protocol driven and choice depends on the treating physician, but increasingly carotid stenting is considered first to avoid the morbidity associated with redo carotid endarterectomy. 

In patients undergoing stenting for restenosis, dual antiplatelet therapy is used for the first 1-3 months, followed by aspirin alone .[28]

Risk factors such as cigarette smoking, hypercholesterolaemia, diabetes, and hypertension must be managed according to appropriate guidelines.[1][2]

Lifestyle modifications include adopting a healthy diet and increased physical activity and exercise as appropriate.[1][2]

Plus – lipid-lowering therapy

Back
ONGOING
|
carotid restenosis
Plus – 

lipid-lowering therapy

Treatment recommended for ALL patients in selected patient group

High-intensity statin therapy should be started or re-prescribed,​​ treating to a target LDL-cholesterol level of <1.8 mmol/L (<70 mg/dL).[2][46][47]​ Statins have a particularly important role in treating carotid stenosis and patients should be encouraged to persist with these medications. 

Addition of ezetimibe is recommended for those who do not reach lipid targets despite maximum tolerated dose of statin. Additional or alternative treatment with proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors (monoclonal antibodies) should be considered for those patients who do not reach lipid targets despite maximum tolerated dose of statin and ezetimibe, or who are intolerant.[2]

Primary options

atorvastatin: 40-80 mg orally once daily

OR

rosuvastatin: 20-40 mg orally once daily

Secondary options

atorvastatin: 40-80 mg orally once daily

or

rosuvastatin: 20-40 mg orally once daily

-- AND --

ezetimibe: 10 mg orally once daily

OR

atorvastatin: 40-80 mg orally once daily

or

rosuvastatin: 20-40 mg orally once daily

-- AND --

ezetimibe: 10 mg orally once daily

-- AND --

alirocumab: 75-150 mg subcutaneously every 2 weeks; or 300 mg subcutaneously every 4 weeks

or

evolocumab: 140 mg subcutaneously every 2 weeks; or 420 mg subcutaneously once monthly

OR

alirocumab: 75-150 mg subcutaneously every 2 weeks; or 300 mg subcutaneously every 4 weeks

OR

evolocumab: 140 mg subcutaneously every 2 weeks; or 420 mg subcutaneously once monthly

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Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

Use of this content is subject to our disclaimer