Treatment of Symptomatic and Asymptomatic Carotid Disease in the Elderly

Definitions. Symptomatic carotid stenosis = an ipsilateral stroke, TIA or amaurosis fugax within the preceding 6 months. Asymptomatic = stenosis detected on imaging or from a bruit, with no such event. Severity is quantified by the NASCET method on Doppler ultrasound, CT angiography or MR angiography, with a second modality used to confirm before intervention.

Best medical therapy — for every patient, symptomatic or not. High-intensity statin (atorvastatin 40–80 mg or rosuvastatin 20–40 mg; LDL target <70 mg/dL, and <55 mg/dL in very-high-risk patients), antiplatelet therapy (aspirin 75–150 mg or clopidogrel 75 mg, with a short course of dual therapy after TIA or minor stroke), blood pressure <130/80 mmHg, glycaemic control, smoking cessation, exercise and weight management.

Symptomatic disease — revascularisation. Carotid endarterectomy (CEA) is clearly beneficial for 70–99% stenosis — NASCET showed an absolute risk reduction of about 16% at 2 years (NNT approximately 6). Benefit for 50–69% stenosis is moderate and greatest in men, patients over 75, and hemispheric rather than retinal events. There is no benefit, and possible harm, below 50%; near-occlusion and total occlusion are not revascularised.

Timing and quality standards. Revascularise within 2 weeks of the index event — benefit falls sharply thereafter, and delaying “to let things settle” is wrong. The procedure is only worthwhile if the unit’s perioperative stroke or death rate is below 6% for symptomatic and below 3% for asymptomatic disease.

Endarterectomy versus stenting in older adults. CEA is preferred in the elderly. The CREST trial showed significantly higher periprocedural stroke with stenting, particularly above the age of 70, because of aortic arch atheroma and vessel tortuosity, while CEA carried a modestly higher risk of myocardial infarction. Stenting is reserved for a hostile neck (previous surgery or radiotherapy), surgically inaccessible high lesions, restenosis, or severe cardiorespiratory disease precluding anaesthesia.

Asymptomatic disease — the geriatric decision. The classical trials (ACAS, ACST-1) showed only about 1% absolute benefit per year, and only if life expectancy exceeds 5 years and the operative risk is under 3%; that margin has narrowed further as medical therapy has improved. In a frail older patient with limited life expectancy, dementia or high operative risk, best medical therapy alone is the correct answer — the decision must follow a comprehensive geriatric assessment, not the stenosis percentage alone.

CREST-2 (NEJM, 21 November 2025) — a paradigm shift in asymptomatic carotid stenosis. Two parallel randomised, observer-blinded trials in 2,485 patients with asymptomatic stenosis ≥70%, all receiving protocol-driven intensive medical therapy. Stenting plus intensive medical therapy reduced the 4-year primary outcome (2.8% vs 6.0%, p=0.02), whereas endarterectomy showed no significant benefit over intensive medical therapy alone (3.7% vs 5.3%, p=0.24). Rates of disabling stroke were low in every group. Taken with SPACE-2 and ECST-2, accompanying editorials concluded there is no longer a routine role for carotid endarterectomy in asymptomatic stenosis, and advised starting intensive medical therapy immediately and deferring revascularisation until symptoms develop. CREST-2 does not alter the strong indication for CEA in symptomatic 70–99% stenosis.