Managing asymptomatic carotid stenosis

The incidental finding of a carotid stenosis is common in patients with cardiovascular risk factors. The stenosis is considered asymptomatic if it is not associated with stroke/TIA symptoms, or if the stroke/TIA occurs in an area of the brain supplied by another vessel. Asymptomatic carotid stenosis has a low risk of causing a stroke—with intensive medical management of cardiovascular risk factors, the annual stroke risk is less than 1%.

While the stroke rate can be reduced by performing carotid endarterectomy, studies show that the benefit is small, and the procedure itself has a significant stroke rate. Since the studies were performed, medical therapy to manage cardiovascular risk factors has improved substantially. Overall, evidence at the time of writing supports treating all patients with an asymptomatic carotid stenosis with intensive medical therapy (for advice on cardiovascular disease risk modification, see the Cardiovascular guideline).

There is no role for carotid artery stenting for asymptomatic stenosis.