Nonoperative management of patients with symptomatic carotid stenosis

• 成果类型: Review
• 署名作者: Yen, Matthew; Goldstein, Larry B.; Silver, Brian; Chaturvedi, Seemant
• 署名单位: University System of Maryland; University of Maryland Baltimore; University System of Maryland; University of Maryland Baltimore; University of Kentucky
• 刊物名称: SEMINARS IN VASCULAR SURGERY
• ISSN/ISSBN: 0895-7967; 1558-4518
• DOI: 10.1053/j.semvascsurg.2026.01.006
• 发表日期: 2026-03
• 页码: 34-40
• 关键词: Atherosclerosis; statins; Antiplatelet therapy; hypertension; MEDICAL THERAPY; STROKE RISK; plaque

摘要

The interventional management of symptomatic carotid disease (ie, endarterectomy, angioplasty/stenting, or transcarotid artery revascularization) has traditionally involved correcting the area of arterial narrowing, guided by stenosis severity combined with medical therapy, and has been recommended by the 2021 American Heart Association Secondary Stroke Prevention Guidelines. Despite this traditional practice, advances in medical therapy show promise in reducing recurrent stroke without the need for interventional procedures in the setting of low-to-intermediate-risk carotid lesions. We review current evidence for the non-operative management of symptomatic carotid disease, focusing on markers of plaque vulnerability, risk calculators, and the efficacy of intensive medical therapy. The objective of this review was to illustrate that medical management of symptomatic carotid disease may be a reasonable alternative to surgical intervention in select patients. High-risk features such as intraplaque hemorrhage, a large lipid-rich necrotic core, a thin fibrous cap, plaque ulceration, vessel wall enhancement, and microembolic activity found on transcranial Doppler ultrasound strongly predict recurrent ischemic events and favor revascularization. In contrast, their absence supports medical management. Risk stratification tools such as the Carotid Artery Risk score and PLAQUE Radiology Scoring system have demonstrated potential utility for identifying low-risk patients who are good candidates for medical therapy. Guideline-directed medical therapy uses antiplatelet agents, intensive lipid-lowering therapy, blood pressure control, diabetes management, and structured lifestyle interventions. Contemporary clinical trials such as the Second European Carotid Surgery Trial and CASCOM are evaluating the comparative effectiveness of revascularization versus intensive medical therapy, with interim data suggesting comparable outcomes in appropriately selected patients. In the modern era, medical management of symptomatic carotid stenosis is safe and effective for patients lacking high-risk plaque features. Integration of imaging biomarkers, validated risk calculators, and structured risk factor modification programs offers a precision-medicine approach that may redefine treatment algorithms and aid in patient management. (c) 2026 Elsevier Inc. All rights are reserved, including those for text and data mining, AI training, and similar technologies.