Carotid Stenosis Treatment: Systematic Review with ☸️SAIMSARA.

• Generated: 2026-02-04 11:03:06 CET
• Plan: Pro (expanded craft tokens; source: Europe PMC)
• Source: Europe PMC
• Scope: Titles/Abstracts (tiab)
• Keyword Gate: Fuzzy (≥60% of required terms, minimum 2 terms matched in title/abstract)
• Total Abstracts/Papers: 5816
• Downloaded Abstracts/Papers: 5816
• Included original Abstracts/Papers: 3387
• Total study participants (naïve ΣN): 3631941

• Bias: Qualitatively inferred from study design fields. Retrospective cohort studies and case series inherently carry a higher risk of selection and reporting bias compared to prospective cohort studies and randomized controlled trials (RCTs). Many studies lacked specified directionality or detailed follow-up periods, limiting certainty in long-term outcomes. Small sample sizes in case reports and some cohort studies also limit generalizability.

• Comparative Efficacy of Revascularization Techniques: Carotid endarterectomy (CEA) is often considered the gold standard, demonstrating superior outcomes in terms of stroke prevention compared to carotid artery stenting (CAS) in some symptomatic patient populations (e.g., 30-day stroke rate: 2.5% for CEA vs. 7.5% for CAS in symptomatic patients [1073]; OR 1.72 for death/stroke with endovascular vs. endarterectomy [1830]). However, CAS may offer a lower risk of myocardial infarction [1610] and cranial nerve injury [924, 2509].
• Role of Medical Therapy: Optimized medical therapy (OMT) is foundational for all patients with carotid stenosis, with ongoing debate regarding the added benefit of revascularization for asymptomatic or low-risk symptomatic stenosis [85, 109, 183, 516, 582, 600, 1118]. Statin treatment, for example, is associated with a lower risk of radiation-induced carotid stenosis progression [34] and can increase plaque GSM [564].
• Emerging Endovascular Techniques and Adjuncts: Transcarotid artery revascularization (TCAR) is gaining prominence, showing superior perioperative outcomes compared to transfemoral CAS (TFCAS), with significantly lower rates of stroke and death [87]. Intravascular lithotripsy (IVL) appears valuable for severely calcified lesions, achieving technical success and excellent stent expansion [18, 956]. Novel stents like the CGuard stent demonstrate safety and efficacy with low perioperative neurological events [333, 334, 836, 2126].
• Inflammation, Biomarkers, and Risk Stratification: Inflammatory processes play a role in CAS progression and treatment outcomes, evidenced by increased carotid perivascular adipose tissue (CPVAT) after surgery [1] and elevated Lp(a) levels associated with plaque ulceration [49]. Biomarkers like NGAL are elevated in type 2 diabetics with CAS and reduced by metformin [812]. Risk models incorporating intraplaque hemorrhage and stenosis degree aid in identifying high-risk patients [166, 680].
• Hemodynamic and Anatomical Considerations: Post-treatment anatomical and hemodynamic changes, including contralateral artery responses and wall shear stress (WSS) alterations, are critical for understanding outcomes [2, 179, 367]. Tandem lesions, complex anatomy (e.g., retropharyngeal ICA, kinking), and severe calcification pose unique challenges requiring tailored approaches [114, 155, 163, 18, 419, 1146].
• Cognitive and Neurological Outcomes: Carotid revascularization can improve attentional performance [58], cognitive function [372, 626, 1600, 2049, 2114], and retinal microcirculation [240, 399, 681] in CAS patients. However, procedures carry risks such as cerebral hyperperfusion syndrome (CHS) [390, 508, 834, 1352] and silent brain infarcts (SBIs) [427, 1529].
• Special Patient Populations and Comorbidities: Treatment decisions are influenced by age (e.g., CAS higher stroke/death risk in 75-79 years vs. CEA [394]), comorbidities (e.g., hypertension, diabetes [11, 143, 1528]), and prior radiation exposure for head and neck cancer [34, 151, 170, 388, 646, 940, 1062, 1075, 1235, 1240, 1397, 1398, 1724, 2028, 2834, 2864, 2942, 3128, 3335]. Disparities in revascularization rates exist based on gender, race, and ethnicity [134, 933].

• CEA Preference for Stroke Risk: For symptomatic carotid stenosis, CEA remains a primary recommendation due to a generally lower risk of perioperative and long-term stroke compared to CAS [1610, 1830, 2426].
• CAS for High-Risk Patients: CAS can be a viable alternative for patients deemed high surgical risk for CEA, or in specific anatomical conditions, offering advantages like lower myocardial infarction risk [1610, 924] and reduced cranial nerve injury [924, 2509].
• Importance of Medical Management: Optimal medical therapy (OMT), including statins and antiplatelet agents, is crucial for all patients, with some studies suggesting it alone may be sufficient for certain asymptomatic or low-risk symptomatic cases [85, 183, 516, 582, 600, 1118].
• TCAR as a Promising Option: Transcarotid artery revascularization (TCAR) is emerging as a safe and effective treatment, showing superior perioperative outcomes compared to transfemoral CAS (TFCAS) and comparable prognosis to CEA, with lower MI and cranial nerve injury rates [87, 924, 1075].
• Personalized Treatment Approach: Treatment decisions should be individualized, considering patient age, symptom status, comorbidities (e.g., radiation-induced stenosis, concurrent cardiac disease), anatomical complexity, and risk of complications like hyperperfusion syndrome or restenosis [143, 394, 508, 569, 736, 1189].

• Optimal Medical Therapy Efficacy: Randomized trials are needed to define the best medical treatment and identify specific asymptomatic carotid stenosis patient subgroups who would benefit most from invasive treatment [109, 346, 882].
• Long-term TCAR Outcomes: Further randomized trials are required to fully investigate the long-term efficacy and safety of TCAR compared to established treatments like CEA and CAS [45].
• Biomarkers for Risk Stratification: Research into novel biomarkers (e.g., Lp(a), NGAL, BMP6, inflammatory markers) and advanced imaging (e.g., plaque vulnerability, WSS) is needed to improve personalized stroke risk prediction and guide treatment decisions [49, 104, 166, 215, 680, 812, 1021].
• Cognitive and Quality of Life Outcomes: Prospective studies should consistently evaluate the impact of different treatment modalities on long-term cognitive function, sleep quality, and health-related quality of life [9, 58, 372, 459, 626, 1032].
• Management of Complex Lesions: Further research is needed to optimize treatment strategies for complex carotid lesions, such as tandem occlusions, severely calcified plaques, radiation-induced stenosis, and those with unusual anatomical variants [18, 114, 155, 163, 419, 956, 1146].

• Heterogeneity of Studies — Varied study designs, populations, and outcome measures limit direct comparability and meta-analysis of all reported metrics.
• Lack of Long-Term Follow-up — Many studies, particularly for newer techniques, lack extensive long-term follow-up data, hindering assessment of durability and late complications.
• Inconclusive RCTs — Some large randomized controlled trials (e.g., SPACE-2) were prematurely stopped or had inconclusive findings, limiting definitive comparisons between treatment strategies.
• Reporting Bias — Case series and reports may disproportionately highlight successful or novel interventions, potentially underrepresenting complications or less favorable outcomes.
• Limited Generalizability — Studies often focus on specific patient subgroups or settings, making it challenging to generalize findings to broader, diverse populations.

• Standardize Outcome Reporting — Implement core outcome sets for stroke, cognitive function, and quality of life across all carotid stenosis trials.
• Comparative Effectiveness Research — Conduct large, pragmatic RCTs comparing TCAR, CAS, and CEA in diverse patient populations, including those with comorbidities.
• Biomarker-Guided Trials — Design trials that use advanced imaging and circulating biomarkers to stratify patients and tailor treatment allocation.
• Longitudinal Cognitive Assessment — Integrate comprehensive cognitive and neurological assessments into long-term follow-up for all carotid revascularization studies.
• Develop AI Predictive Models — Utilize machine learning to predict treatment outcomes, such as hyperperfusion syndrome and in-stent restenosis, based on patient and lesion characteristics.