An algorithmic approach to patient-specific treatment: medical management, carotid endarterectomy, carotid artery stenting and transcarotid artery revascularization

The treatment of asymptomatic carotid artery stenosis (AsxCS) has been controversial over the past three decades. In this article an algorithmic approach to patient-specific treatment is described whether medical management or a carotid intervention is considered, including carotid endarterectomy (CEA), transfemoral carotid artery stenting (TFCAS), and/or transcarotid artery revascularization (TCAR). This article will summarize the commonly-quoted randomized controlled trials for both TFCAS and CEA which were published over the past two decades for both symptomatic (SxCS) and AsxCS, and create an algorithmic approach to patient-specific treatment according to risk stratification. Patients should be classified according to symptomatic status, followed by risk stratification. Patients with <70% AsxCS or <50% SxCS should be treated with best medical therapy alone. However, patients with ≥70% AsxCS and ≥50% SxCS should undergo CEA or TFCAS or TCAR with best medical therapy according to individual risk stratification. These three modalities can be complementary and very helpful in selecting proper therapy according to their risk.