Common carotid artery (CCA) disease represents a challenging subset of cerebrovascular pathology with unique anatomical and hemodynamic considerations distinct from the more extensively studied internal carotid artery stenosis. Stenosis at the CCA origin from the aortic arch occurs with an approximate incidence of 0.5 to 6.4% of angiographic imaging cases, with approximately 17% of symptomatic patients developing tandem disease involving the carotid bifurcation. The pathophysiology of stroke risk involves hemodynamic compromise, embolic phenomena, and the cumulative effects of multilevel disease, although natural history data remain limited. Management decisions are guided primarily by observational data and expert consensus due to the absence of randomized controlled trials. Current evidence-based guidelines recommend optimal medical management for asymptomatic patients and reserve intervention for symptomatic individuals. When intervention is pursued, an "endovascular-first" approach is favored based on systematic review data showing lower 30-day mortality and stroke rates compared with open surgery, despite higher restenosis rates (9 vs. 1.3%). However, endovascular treatment of tandem lesions increases stroke and death risk in asymptomatic patients. Hybrid procedures combining open and endovascular techniques demonstrate intermediate outcomes but elevated risk in symptomatic patients. Treatment selection requires individualized assessment incorporating symptom status, lesion characteristics, technical feasibility, patient anatomy, and surgeon experience. Substantial knowledge gaps persist regarding natural history, long-term comparative effectiveness, optimal management of tandem disease, and the evolving role of contemporary medical therapy, underscoring the need for continued investigation in this complex area of vascular medicine.
Snyder et al. (2026) studied this question.