Appropriateness of care: Asymptomatic carotid stenosis including transcarotid artery revascularization

Carotid artery stenosis remains one of the most commonly treated diagnoses by vascular specialists in the United States. The optimal management of carotid stenosis remains controversial however, with notable variation surrounding diagnostic imaging modalities, longitudinal surveillance, medical therapies, and procedural interventions. Data from high quality randomized controlled trials and observational studies form the foundation for current management paradigms and societal guidelines that inform clinical practice. Presently, a diagnosis of carotid disease is most often established with duplex ultrasound, and supplemental cross-sectional imaging using computed tomography or magnetic resonance angiography as needed to provide additional anatomic information. Currently, all patients with documented occlusive disease should receive goal directed medical therapy, with antiplatelet agents and a lipid reduction strategy, most commonly with a statin. Those patients with severe carotid stenosis and an acceptable life expectancy may be considered for carotid artery revascularization. The proceduralist should optimally consider a shared decision-making approach where the tradeoffs of revascularization can be carefully considered with the patient, to optimize informed therapeutic decision making. In current practice, three distinct procedure options exist to treat carotid artery stenosis, including carotid endarterectomy, transfemoral carotid artery stenting, and transcarotid artery revascularization. It should be noted that each procedure, while often used interchangeably in most clinical settings, carry technical nuances and outcome disparities. In this review, we explore each of these topics and outline various approaches surrounding the appropriate use of treatments for patients with asymptomatic carotid artery stenosis.