Carotid artery stenosis remains an important underlying cause of stroke, the fifth leading cause of death in the United States.[1] While documented population-based epidemiology rates vary, it is currently estimated that carotid disease affects 5-7% of the adult population over 50, and its incidence increases linearly with advancing age.[2,3] Risk factors for carotid stenosis are those classically associated with atherosclerotic vascular disease, and include age, male sex, smoking, hypertension, dyslipidemia, and family history.[4] These prevalent risk factors and co-morbidities make carotid disease one of the most common diagnoses prompting consultation by vascular specialists.

The treatment of carotid artery stenosis currently includes both procedural and non-procedural based management strategies. Guideline directed medical therapy (GDMT), described below, forms the basis for the treatment of carotid disease.[5] In addition to GDMT, procedures for carotid revascularization can be performed to further reduce a patient's longitudinal risk of stroke. Three primary procedure options exist in contemporary practice and include: carotid endarterectomy (CEA), transfemoral carotid artery stenting (TF-CAS), and transcarotid artery stenting (TCAR).[6] Currently, more than 100,000 carotid revascularization procedures are performed annually in the U.S, with well documented clinical risks and benefits.[7], [8], [9], [10]

Nevertheless, the optimal management of asymptomatic carotid stenosis remains one of the most controversial topics in contemporary vascular practice. Interestingly, there are persistent advocates for both medical therapy and intervention. Notably, while some advocate for a more aggressive intervention-based treatment approach,[11] others maintain that advances in medical therapy have rendered procedures obsolete for patients with asymptomatic carotid stenosis.[12] This ongoing variation in practice transpires in the setting of dozens of randomized trials to inform practice and thus has led the Society for Vascular Surgery to consider the management of asymptomatic carotid disease as a top research priority.[13] Accordingly, in this review, we will discuss the reasons for some of these controversies in management, the data underlying them, and some important points for treating patients.