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Duplex ultrasound

Individual risk assessmenta

Average-to-high surgical risk

<60% carotid stenosis 60–99% carotid stenosis 100% carotid occlusion

Asymptomatic patient

OMT (Class I)

Revascularization

(Class III)

Revascularization

(Class IIb)

CTA and/or MRA (incl. aortic arch)

CEA or CAS/TCAR decision by vascular team based on an individual patient approach

Surgical/endovascular risk assessmenta Routine revascularization

(Class III)

OMT (Class I)

Revascularization

(Class III)

OMT (Class I)

Vascular team and neurologist

N Y

Duplex ultrasound CTA and/or MRA (incl. aortic arch)

<50% carotid stenosis 50–69% carotid stenosis 100% carotid occlusion

Symptomatic patient

OMT (Class I)

Routine revascularization

(Class III) OMT (Class I)

Revascularization

(Class III)

OMT (Class I)

Revascularization

(Class IIa) 70–99% carotid stenosis

OMT (Class I)

Revascularization

(Class I)

CEA or CAS/TCAR decision by vascular team based on an individual patient approach

Figure 18 Algorithm of carotid artery stenosis management. CAS, carotid artery stenting; CEA, carotid endarterectomy; CTA, computed tomography angiography; MRA, magnetic resonance angiography; OMT, optimal medical treatment; TCAR, transcarotid artery revascularization; TIA, transient ischaemic attack. aAssess presence of high-risk features according to Table 11. If surgery/revascularization is considered, assess the overall risk related to surgery according to Table 12.

ESC Guidelines                                                                                                                                                                                          3593

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