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Screening, diagnosis and management of carotid artery stenosis: a state-of-the-art review
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All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.
Published: 21 August 2026
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Stroke causes substantial morbidity and mortality in the United States, with nearly 800,000 cases each year. Carotid artery stenosis (CAS) accounts for 2030% of ischemic strokes. CAS reflects systemic atherosclerosis and affects roughly 1.5% of adults worldwide aged 3079 years (~58 million people), while moderate-to-severe asymptomatic CAS affects 48% of U.S. adults. Severe asymptomatic CAS (7099% stenosis) affects 0.5% of adults aged ≥65, and meta-analyses estimate a 3.1% prevalence in the general population. Contemporary optimal medical therapy has lowered annual stroke rates in asymptomatic CAS to ~1.3% for stenosis <75% and 22.5% for stenosis ≥75%, with a five-year ipsilateral stroke risk of 5% in a large U.S. cohort. These findings support selective screening in high-risk groups and align with the U.S. Preventive Services Task Force recommendation against routine screening in asymptomatic adults. Symptomatic and asymptomatic CAS differ in stroke risk and treatment benefit. Symptomatic CAS carries high early recurrence risk, with stroke recurrence exceeding 18% within 30 days. The Asymptomatic Carotid Surgery Trial found that about half of ischemic strokes in patients with >60% asymptomatic CAS caused disability or death. Carotid duplex ultrasonography serves as the firstline diagnostic tool, while CT angiography and magnetic resonance angiography provide complementary imaging. Clinicians reserve digital subtraction angiography for complex cases. Luminal stenosis alone does not predict risk, as vulnerable plaque features such as intraplaque hemorrhage, ulceration, and other morphologic markers can cause events even when stenosis is <50%. Contemporary evidence establishes optimal medical therapy as foundational therapy. Revascularization remains essential for selected symptomatic patients but remains controversial in asymptomatic disease. In the North American Symptomatic Carotid Endarterectomy Trial, carotid endarterectomy reduced the five-year risk of death or stroke by 29% in patients with 5069% stenosis and substantially lowered major stroke or death in those ≥70% stenosis. In symptomatic disease, a meta-analysis showed lower 30day mortality with carotid endarterectomy than with stenting (1.4% vs. 1.9%), lower stroke rates (4.6% vs. 8.5%), and higher rates of myocardial infarction with endarterectomy (1.6% vs. 0.8%). Severe restenosis at five years also favored endarterectomy (5.8% vs. ≥10%). Transcarotid artery revascularization (TCAR) has produced favorable registry outcomes, with peri-procedural stroke or death rates of 1.2% for TCAR, 1.1% for carcinoembryonic antigen, and 1.8% for stenting in asymptomatic CAS. However, randomized evidence remains limited. This state-of-the-art review synthesizes contemporary evidence on screening, diagnosis, and management of CAS in asymptomatic and symptomatic populations.
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How to Cite
1.
Siddiqi AK, Khan SU, Mithani I, Khan MS. Screening, diagnosis and management of carotid artery stenosis: a state-of-the-art review. Global Cardiol [Internet]. 2026 Aug. 21 [cited 2026 Aug. 25];. Available from: https://www.globalcardiology.info/site/article/view/113
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