Recent advances and controversial issues in the optimal management of asymptomatic carotid stenosis.

Objective: The optimal management of patients with asymptomatic carotid stenosis (AsxCS) is enduringly controversial. We updated our 2021 Expert Review and Position Statement, focusing on recent advances in the diagnosis and management of patients with AsxCS.
Methods: A systematic review of the literature was performed up to August 1, 2023, using PubMed/PubMed Central, EMBASE and Scopus. The following keywords were used in various combinations: "asymptomatic carotid stenosis," "carotid endarterectomy" (CEA), "carotid artery stenting" (CAS), and "transcarotid artery revascularization" (TCAR). Areas covered included (i) improvements in best medical treatment (BMT) for patients with AsxCS and declining stroke risk, (ii) technological advances in surgical/endovascular skills/techniques and outcomes, (iii) risk factors, clinical/imaging characteristics and risk prediction models for the identification of high-risk AsxCS patient subgroups, and (iv) the association between cognitive dysfunction and AsxCS.
Results: BMT is essential for all patients with AsxCS, regardless of whether they will eventually be offered CEA, CAS, or TCAR. Specific patient subgroups at high risk for stroke despite BMT should be considered for a carotid revascularization procedure. These patients include those with severe (≥80%) AsxCS, transcranial Doppler-detected microemboli, plaque echolucency on Duplex ultrasound examination, silent infarcts on brain computed tomography or magnetic resonance angiography scans, decreased cerebrovascular reserve, increased size of juxtaluminal hypoechoic area, AsxCS progression, carotid plaque ulceration, and intraplaque hemorrhage. Treatment of patients with AsxCS should be individualized, taking into consideration individual patient preferences and needs, clinical and imaging characteristics, and cultural, ethnic, and social factors. Solid evidence supporting or refuting an association between AsxCS and cognitive dysfunction is lacking.
Conclusions: The optimal management of patients with AsxCS should include BMT for all individuals and a prophylactic carotid revascularization procedure (CEA, CAS, or TCAR) for some asymptomatic patient subgroups, additionally taking into consideration individual patient needs and preference, clinical and imaging characteristics, social and cultural factors, and the available stroke risk prediction models. Future studies should investigate the association between AsxCS with cognitive function and the role of carotid revascularization procedures in the progression or reversal of cognitive dysfunction.
Competing Interests: Disclosures J.F.M. is co-Principal Investigator for the Clinical Coordinating Center of the CREST-2 multicenter randomized clinical trial (U01NS080168) and Principal Investigator of the Long-term Observational Extension of participants in the CREST-2 randomized clinical trial (C2LOE; U01NS119169). M.L.S. is the Principal Investigator of the ROADSTER-3 trial and is the Chair of the TCAR Surveillance Program in the Vascular Quality Initiative. L.H.B., P.J.N., and M.M.B. are co-Principal Investigators for the 2nd European Carotid Surgery Trial (ECST-2). P.S. is a consultant for Silk Road, Philips, Surmodics, Medtronic, Boston Scientific, Cagent, and LimFlow. E.A.S. has received research grants from the Food & Drug Administration (FDA), SCAI, BD, Boston Scientific, Cook, Laminate Medical, Medtronic, Philips, and NIH/NHLBIK23HL150290. He has received Consulting/Speaker fees from Abbott, Bayer, BD, Boston Scientific, Cook, Cordis, Heartflow, Inari, InfraRedx, Medtronic, Philips, RapidAI, Shockwave, and VentureMed. D.P.M. has given talks, acted as a consultant or attended conferences sponsored by Amgen and Novo Nordisk. B.K.L. is co-Principal Investigator of the CREST-2 multicenter randomized clinical trial (U01NS080168), Principal Investigator of the CREST-2 Registry (C2R; NCT02240862) and Principal Investigator for the Asymptomatic Carotid Stenosis and Cognitive Function Study (ACCOF; CX001621). The other authors have no conflicts of interest.
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