Subscribe for unlimited access to DynaMed content, CME/CE & MOC credit, and email alerts on content you follow.

Already subscribed? Sign in now

Learn more about CME

Carotid Artery Stenosis

MoreVert
AddCircleOutlineFollow
ShareShare
AddCircleOutlineFollow
Follow
ShareShare
Share

General Information

Description

  • narrowing of carotid artery, most commonly due to atherosclerosis, leading to increased risk of transient ischemic attack and stroke1,2,3

Also called

  • carotid artery disease
  • carotid artery atherosclerosis

Definitions

  • extracranial carotid and vertebral artery disease - any of several disorders affecting the arteries supplying blood to the brain, most commonly due to atherosclerosis1

References

General references used

  1. Brott TG, Halperin JL, Abbara S, et al; American College of Cardiology Foundation, American Heart Association Task Force on Practice Guidelines, American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, Society for Vascular Surgery, American Academy of Neurology and Society of Cardiovascular Computed Tomography. 2011 ASA/ACCF/AHA/AAN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease: executive summary. Stroke. 2011 Aug;42(8):e420-63OpenInNewfull-textOpenInNew, correction can be found in Stroke 2011 Aug;42(8):e541
  2. Grotta JC. Clinical practice. Carotid stenosis. N Engl J Med. 2013 Sep 19;369(12):1143-50OpenInNew, commentary can be found in N Engl J Med 2013 Dec 12;369(24):2359OpenInNew
  3. Thapar A, Jenkins IH, Mehta A, Davies AH. Diagnosis and management of carotid atherosclerosis. BMJ. 2013 Mar 18;346:f1485OpenInNew, correction can be found in BMJ 2013 Mar 18;346:f2420, commentary can be found in BMJ 2013 Apr 16;346:f2290OpenInNew
  4. Taussky P, Hanel RA, Meyer FB. Clinical considerations in the management of asymptomatic carotid artery stenosis. Neurosurg Focus. 2011 Dec;31(6):E7OpenInNew
  5. Mokin M, Dumont TM, Kass-Hout T, Levy EI. Carotid and vertebral artery disease. Prim Care. 2013 Mar;40(1):135-51OpenInNew
  6. De Rango P, Brown MM, Leys D, et al. Management of carotid stenosis in women: consensus document. Neurology. 2013 Jun 11;80(24):2258-68OpenInNewfull-textOpenInNew

Recommendation grading systems used

  • Expert panel uses Grades of Recommendation, Assessment, Development, and Evaluation (GRADE)
    • strength of recommendation
      • Grade 1 - strong recommendation, benefit clearly outweighs risk and can be accepted with high degree of confidence
      • Grade 2 - weak recommendation, benefits and risks more closely matched and more dependent on specific clinical scenarios
    • levels of evidence
      • Level A - high-quality evidence
      • Level B - moderate-quality evidence
      • Level C - low-quality evidence
    • Reference - Consensus document on management of carotid artery stenosis in women (23751919Neurology 2013 Jun 11;80(24):2258OpenInNewfull-textOpenInNew)
  • American Heart Association/American Stroke Association (AHA/ASA) 2018 recommendation grading system
    • classifications of recommendations
      • Class I - procedure or treatment should be performed or administered
      • Class IIa - reasonable to perform procedure or administer treatment, but additional studies with focused objectives needed
      • Class IIb - procedure or treatment may be considered; additional studies with broad objectives needed, additional registry data would be useful
      • Class III - procedure or treatment should not be performed or administered because it is not helpful or may be harmful
        • Class III ratings may be subclassified as Class III No Benefit or Class III Harm
    • levels of evidence
      • Level A - high-quality evidence from > 1 randomized controlled trial or meta-analysis of high-quality randomized controlled trials
      • Level B-R - moderate-quality evidence from ≥ 1 randomized controlled trial or meta-analysis of moderate-quality randomized controlled trials
      • Level B-NR - moderate-quality evidence from ≥ 1 well-designed nonrandomized trial, observational studies, or registry studies, or meta-analysis of such studies
      • Level C-LD - randomized or nonrandomized studies with methodological limitations or meta-analyses of such studies
      • Level C-EO - consensus of expert opinion based on clinical experience
  • American Stroke Association/American College of Cardiology Foundation/American Heart Association (ASA/ACCF/AHA) grades of recommendation
    • classifications of recommendations
      • Class I - effective; procedure or treatment should be performed or administered
      • Class IIa - probably effective; reasonable to perform procedure or administer treatment, but additional studies with focused objectives needed
      • Class IIb - effectiveness uncertain; procedure or treatment may be considered; additional studies with broad objectives needed, additional registry data would be useful
      • Class III - procedure or treatment should not be performed or administered because it is not helpful or may be harmful
        • Class III ratings may be subclassified as Class III No Benefit or Class III Harm
    • levels of evidence
      • Level A - data derived from multiple randomized clinical trials or meta-analyses
      • Level B - data derived from single randomized trial or nonrandomized studies
      • Level C - only consensus opinions of experts, case studies, or standard of care
    • References
  • Society for Vascular Surgery (SVS) grading system for recommendations
    • strength of recommendation
      • GRADE 1 - strong recommendation; high confidence that benefit clearly outweighs risk
      • GRADE 2 - weak recommendation; benefit and risk closely balanced
    • levels of evidence
      • Level A - high-quality evidence; further study unlikely to change conclusions
      • Level B - moderate-quality evidence; further study likely to affect conclusions
      • Level C - low-quality evidence; further study very likely to change conclusions
  • American College of Chest Physicians (ACCP) grades
    • Grade 1 - strong recommendation based on clear risk/benefit balance
    • Grade 2 - weak recommendation based on unclear or close risk/benefit balance
    • Grade A - high-quality evidence based on consistent evidence from randomized trials without important limitations or exceptionally strong evidence from observational studies
    • Grade B - moderate-quality evidence based on randomized trials with important limitations (inconsistent results, methodologic flaws, indirect or imprecise results) or very strong evidence from observational studies
    • Grade C - low- or very low-quality evidence based on evidence for ≥ 1 critical outcome from observational studies, case series, or randomized trials with serious flaws or indirect evidence
    • Reference - ACCP evidence-based clinical practice guideline on methodology for development of antithrombotic therapy and prevention of thrombosis (22315256Chest 2012 Feb;141(2 Suppl):53SOpenInNewfull-textOpenInNew), commentary can be found in 23546508Chest 2013 Apr;143(4):1190OpenInNew
  • United States Preventive Services Task Force (USPSTF) grades of recommendation (June 2007 to June 2012)
    • Grade A - USPSTF recommends the service with high certainty of substantial net benefit
    • Grade B - USPSTF recommends the service with high certainty of moderate net benefit or moderate certainty of moderate-to-substantial net benefit
    • Grade C - clinicians may provide the service to select patients depending on individual circumstances; however, only small benefit is likely for most individuals without signs or symptoms
    • Grade D - USPSTF recommends against providing the service with moderate-to-high certainty of no net benefit or harms outweighing benefits
    • Grade I - insufficient evidence to assess balance of benefits and harms
    • Reference - USPSTF Grade DefinitionsOpenInNew

Synthesized Recommendation Grading System for DynaMed

  • DynaMed systematically monitors clinical evidence to continuously provide a synthesis of the most valid relevant evidence to support clinical decision-making (see 7-Step Evidence-Based MethodologyOpenInNew).
  • Guideline recommendations summarized in the body of a DynaMed topic are provided with the recommendation grading system used in the original guideline(s), and allow DynaMed users to quickly see where guidelines agree and where guidelines differ from each other and from the current evidence.
  • In DynaMed (DM), we synthesize the current evidence, current guidelines from leading authorities, and clinical expertise to provide recommendations to support clinical decision-making in the Overview & Recommendations section.
  • We use the Grading of Recommendations Assessment, Development and Evaluation (GRADE)OpenInNew to classify synthesized recommendations as Strong or Weak.
    • Strong recommendations are used when, based on the available evidence, clinicians (without conflicts of interest) consistently have a high degree of confidence that the desirable consequences (health benefits, decreased costs and burdens) outweigh the undesirable consequences (harms, costs, burdens).
    • Weak recommendations are used when, based on the available evidence, clinicians believe that desirable and undesirable consequences are finely balanced, or appreciable uncertainty exists about the magnitude of expected consequences (benefits and harms). Weak recommendations are used when clinicians disagree in judgments of relative benefit and harm, or have limited confidence in their judgments. Weak recommendations are also used when the range of patient values and preferences suggests that informed patients are likely to make different choices.
  • DynaMed (DM) synthesized recommendations (in the Overview & Recommendations section) are determined with a systematic methodology:
    • Recommendations are initially drafted by clinical editors (including ≥ 1 with methodological expertise and ≥ 1 with content domain expertise) aware of the best current evidence for benefits and harms, and the recommendations from guidelines.
    • Recommendations are phrased to match the strength of recommendation. Strong recommendations use "should do" phrasing, or phrasing implying an expectation to perform the recommended action for most patients. Weak recommendations use "consider" or "suggested" phrasing.
    • Recommendations are explicitly labeled as Strong recommendations or Weak recommendations when a qualified group has explicitly deliberated on making such a recommendation. Group deliberation may occur during guideline development. When group deliberation occurs through DynaMed-initiated groups:
      • Clinical questions will be formulated using the PICO (Population, Intervention, Comparison, Outcome) framework for all outcomes of interest specific to the recommendation to be developed.
      • Systematic searches will be conducted for any clinical questions where systematic searches were not already completed through DynaMed content development.
      • Evidence will be summarized for recommendation panel review including for each outcome, the relative importance of the outcome, the estimated effects comparing intervention and comparison, the sample size, and the overall quality rating for the body of evidence.
      • Recommendation panel members will be selected to include at least 3 members that together have sufficient clinical expertise for the subject(s) pertinent to the recommendation, methodological expertise for the evidence being considered, and experience with guideline development.
      • All recommendation panel members must disclose any potential conflicts of interest (professional, intellectual, and financial), and will not be included for the specific panel if a significant conflict exists for the recommendation in question.
      • Panel members will make Strong recommendations if and only if there is consistent agreement in a high confidence in the likelihood that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. Panel members will make Weak recommendations if there is limited confidence (or inconsistent assessment or dissenting opinions) that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. No recommendation will be made if there is insufficient confidence to make a recommendation.
      • All steps in this process (including evidence summaries which were shared with the panel, and identification of panel members) will be transparent and accessible in support of the recommendation.
    • Recommendations are verified by ≥ 1 editor with methodological expertise, not involved in recommendation drafting or development, with explicit confirmation that Strong recommendations are adequately supported.
    • Recommendations are published only after consensus is established with agreement in phrasing and strength of recommendation by all editors.
    • If consensus cannot be reached then the recommendation can be published with a notation of "dissenting commentary" and the dissenting commentary is included in the topic details.
    • If recommendations are questioned during peer review or post publication by a qualified individual, or reevaluation is warranted based on new information detected through systematic literature surveillance, the recommendation is subject to additional internal review.

DynaMed Editorial Process

Special acknowledgements

  • The American College of Physicians (Marjorie Lazoff, MD, FACP; ACP Deputy Editor, Clinical Decision Resource) provided review in a collaborative effort to ensure DynaMed provides the most valid and clinically relevant information in internal medicine.
  • DynaMed topics are written and edited through the collaborative efforts of the above individuals. Deputy Editors, Section Editors, and Topic Editors are active in clinical or academic medical practice. Recommendations Editors are actively involved in development and/or evaluation of guidelines.
  • Editorial Team role definitions
    Topic Editors define the scope and focus of each topic by formulating a set of clinical questions and suggesting important guidelines, clinical trials, and other data to be addressed within each topic. Topic Editors also serve as consultants for the internal DynaMed Editorial Team during the writing and editing process, and review the final topic drafts prior to publication.
    Section Editors have similar responsibilities to Topic Editors but have a broader role that includes the review of multiple topics, oversight of Topic Editors, and systematic surveillance of the medical literature.
    Recommendations Editors provide explicit review of DynaMed Overview and Recommendations sections to ensure that all recommendations are sound, supported, and evidence-based. This process is described in "Synthesized Recommendation Grading."
    Deputy Editors are employees of DynaMed and oversee DynaMed internal publishing groups. Each is responsible for all content published within that group, including supervising topic development at all stages of the writing and editing process, final review of all topics prior to publication, and direction of an internal team.

How to cite

National Library of Medicine, or "Vancouver style" (International Committee of Medical Journal Editors):

  • DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No. T116329, Carotid Artery Stenosis; [updated 2018 Nov 30, cited place cited date here]. Available from https://www.dynamed.com/topics/dmp~AN~T116329. Registration and login required.
  • KeyboardArrowRight

    Overview and Recommendations

    • Background

    • Evaluation

    • Management

  • Related Summaries

  • KeyboardArrowRight

    General Information

    • Description

    • Also called

    • Definitions

  • KeyboardArrowRight

    Epidemiology

    • Who is most affected

    • Incidence/Prevalence

    • Risk factors

    • Associated conditions

  • KeyboardArrowRight

    Etiology and Pathogenesis

    • Causes

    • Pathogenesis

  • KeyboardArrowRight

    History and Physical

    • Clinical presentation

    • KeyboardArrowRight

      History

      • History of present illness (HPI)

      • Past medical history (PMH)

      • Family history (FH)

      • Social history (SH)

    • KeyboardArrowRight

      Physical

      • General physical

      • Neck

      • Neuro

  • KeyboardArrowRight

    Diagnosis

    • Making the diagnosis

    • Differential diagnosis

    • Testing overview

    • KeyboardArrowRight

      Imaging studies

      • General considerations

      • Ultrasonography

      • KeyboardArrowRight

        Magnetic resonance angiography (MRA) and computed tomography angiography (CTA)

        • Recommendations

        • Magnetic resonance angiography (MRA)

        • Computed tomography angiography (CTA)

      • Angiography

      • Echocardiography

  • KeyboardArrowRight

    Management

    • Management overview

    • Diet

    • KeyboardArrowRight

      Medications

      • General considerations for medical therapy

      • KeyboardArrowRight

        Antiplatelet therapy

        • Recommendations

        • In patients having carotid endarterectomy

        • In patients not having carotid endarterectomy

      • Antihypertensive therapy

      • Statin therapy

      • Vitamins and minerals

      • Other medications

    • Surgery and procedures

    • Other management

    • Follow-up

  • KeyboardArrowRight

    Complications and Prognosis

    • Complications

    • KeyboardArrowRight

      Prognosis

      • Symptomatic carotid artery stenosis

      • Asymptomatic carotid artery stenosis

  • KeyboardArrowRight

    Prevention and Screening

    • Prevention

    • Screening

  • KeyboardArrowRight

    Quality Improvement

    • Physician Quality Reporting System Quality Measures

    • Choosing Wisely

  • KeyboardArrowRight

    Guidelines and Resources

    • KeyboardArrowRight

      Guidelines

      • United States guidelines

      • United Kingdom guidelines

      • Canadian guidelines

      • European guidelines

    • Review articles

    • MEDLINE search

  • Patient Information

  • KeyboardArrowRight

    ICD Codes

    • ICD-10 codes

  • KeyboardArrowRight

    References

    • General references used

    • Recommendation grading systems used

    • Synthesized Recommendation Grading System for DynaMed

    • DynaMed Editorial Process

    • Special acknowledgements

    • How to cite

Topic Editor
Gabor Toth MD, FAHA
KeyboardArrowDown
Affiliations

Associate Professor, Department of Medicine Neurology, Cleveland Clinic Lerner College of Medicine; Ohio, United States; Associate Director, Endovascular Surgical Neuroradiology Fellowship Program, and Lead, Endovascular Operations, Cleveland Clinic Foundation; Ohio, United States; Staff Physician, Vascular Neurology and Endovascular Neuroradiology, Cleveland Clinic Foundation; Ohio, United States

Conflicts of Interest

Dr. Toth declares no relevant financial conflicts of interest.

Recommendations Editor
Allen Shaughnessy PharmD, M Med Ed, FCCP
KeyboardArrowDown
Affiliations

Professor of Family Medicine and Director of Master Teacher Fellowship, Tufts University; Massachusetts, United States

Conflicts of Interest

Dr. Shaughnessy declares no relevant financial conflicts of interest.

Deputy Editor
Alexander Rae-Grant MD, FRCPC, FAAN
KeyboardArrowDown
Affiliations

Deputy Editor Neurology, DynaMed Plus; Massachusetts, United States; Neurologist, Cleveland Clinic; Ohio, United States

Conflicts of Interest

Dr. Rae-Grant declares no relevant financial conflicts of interest.

Produced in collaboration with American College of Physicians
CheckCircle
Subscribe for unlimited access to DynaMed content.
Already subscribed? Sign in

top