Referral Guidelines for Patients with Carotid Stenosis

Symptomatic Carotid Stenosis

Patients with recent transient ischemic attack (TIA) or non-disabling stroke and ipsilateral carotid stenosis of 50-99% should be urgently evaluated by a vascular specialist, with revascularization ideally performed within the first few days following a non-disabling stroke or TIA, and within 14 days of symptom onset for patients who are not clinically stable in the first few days, as recommended by the American Heart Association 1, 2, 3
Earlier intervention (within 2 weeks) is associated with greater reduction in stroke risk compared to delayed intervention, according to the American Stroke Association 4
Symptomatic stenosis 70-99% is a strong indication for referral with highest benefit from revascularization, as stated by the American College of Cardiology 1, 2

Asymptomatic stenosis 60-99% with high-risk features and life expectancy >5 years should be referred to a vascular specialist, as recommended by the European Society of Cardiology 1, 2, 3
High-risk features that warrant referral include age <75 years, as stated by the European Heart Journal 3
Contralateral TIA/stroke and ipsilateral silent infarcts on brain imaging are also high-risk features that warrant referral, according to the International Journal of Stroke 4

Patients with carotid stenosis requiring coronary artery bypass grafting (CABG) should be evaluated by a vascular specialist, as recommended by the European Heart Journal and the American College of Cardiology 7, 8
Patients with fibromuscular dysplasia affecting carotid arteries should be evaluated by a vascular specialist, according to the Journal of the American College of Cardiology 8

All patients with carotid stenosis should receive optimal medical therapy regardless of referral status, including antiplatelet therapy (aspirin 75-325mg daily) and high-intensity statin therapy, as recommended by the American Heart Association and the American College of Cardiology 1, 4, 5
For symptomatic patients, consider dual antiplatelet therapy (aspirin plus clopidogrel) for at least 21 days, as stated by the European Heart Journal and the American Heart Association 2, 3