Carotid Artery Stenting for Acute Ischemic Stroke with Symptomatic High‑Grade Stenosis

Indications and Patient Selection

Patients with acute ischemic stroke caused by symptomatic carotid stenosis ≥ 70 % (by CTA/MRA) or ≥ 50 % (by catheter angiography) who are poor surgical candidates may be treated with carotid artery stenting (CAS) as an alternative to endarterectomy, provided the operator’s periprocedural stroke/death rate is ≤ 6 %【1】【3】.
Eligible patients must have experienced a stroke or transient ischemic attack within the preceding 6 months and present with a non‑disabling neurological deficit that allows meaningful functional recovery【1】【2】【4】.
CAS is generally not preferred for patients > 70 years because of higher periprocedural stroke rates in this age group, unless specific contraindications to surgery exist【2】【4】【3】.

Anatomic: stenosis located above the C2 vertebra, intrathoracic lesions, contralateral vocal‑cord paralysis, prior radical neck surgery, or open tracheostomy【1】【3】.
Medical: severe cardiac disease (NYHA III‑IV heart failure, unstable angina, need for cardiac surgery within 30 days, recent myocardial infarction), severe chronic lung disease, or age > 80 years【1】【3】.
Prior interventions: radiation‑induced carotid stenosis or restenosis after previous carotid endarterectomy【1】【2】.

The interventionalist must demonstrate documented periprocedural morbidity/mortality rates of 4–6 % for symptomatic patients【1】【2】.
The treating center should routinely audit CAS performance outcomes【2】【3】.

Optimal revascularization is performed within 14 days of the index neurological event, ideally within the first few days if the patient is clinically stable【2】【4】【3】.
Delaying CAS beyond 14 days in stable symptomatic patients markedly reduces the benefit of revascularization【2】【4】.

Pre‑procedure: Initiate dual antiplatelet therapy (DAPT) with aspirin (75–325 mg) plus clopidogrel (75 mg); loading doses are used when the patient is not already on therapy【4】【3】.
Post‑procedure: Continue DAPT for at least 1 month after CAS, then transition to single antiplatelet therapy (aspirin or clopidogrel) indefinitely【4】【3】.
If CAS is deferred, maintain DAPT for 21 days in symptomatic patients with high‑grade stenosis, followed by lifelong single antiplatelet therapy【4】【5】.

Lipid management: Prescribe high‑intensity statin therapy aiming for LDL‑C < 70 mg/dL; in highest‑risk individuals, target LDL‑C < 55 mg/dL with ≥ 50 % reduction from baseline【1】【4】【5】.
Blood pressure control: Maintain systolic/diastolic pressure < 140/90 mmHg; aggressive antihypertensive therapy is emphasized【1】【2】【4】.
Risk‑factor modification: Ensure diabetes glycemic control and enforce smoking cessation as mandatory components of care【1】.

Perform duplex ultrasound of the treated carotid artery within 1 month after CAS【4】.
Conduct annual clinical follow‑up to reassess neurological status, cardiovascular risk factors, and medication adherence【4】【3】.
Continue aggressive medical management without interruption for the patient’s lifetime【1】【2】【4】.

Do not proceed with CAS if the interventionalist cannot demonstrate periprocedural complication rates ≤ 6 %【1】【2】【3】.
Avoid using CAS as first‑line therapy in patients > 70 years unless they are unequivocal non‑surgical candidates; carotid endarterectomy yields superior outcomes in this age group【2】【4】【3】.
Do not delay revascularization beyond 14 days in clinically stable symptomatic patients, as the therapeutic benefit diminishes substantially【2】【4】.
Do not use single antiplatelet therapy during the first month after CAS; DAPT is required to minimize early thrombotic complications【4】【3】.