A 66-year-old man had a right hemispheric TIA with transient left arm weakness 3 weeks ago. Duplex ultrasound shows 80% stenosity of the right internal carotid artery at the origin. He is on aspirin with LDL controlled. What is the most appropriate next step?
- A Carotid endarterectomy within 2 weeks to 6 months of the index event ✓
- B Carotid angioplasty with stenting
- C Continue medical therapy alone and repeat imaging in 6 months
- D Add clopidogrel to aspirin permanently and defer surgery
Correct answer: A. Carotid endarterectomy within 2 weeks to 6 months of the index event
Explanation
For recently symptomatic severe carotid stenosis of 70 to 99% by NASCET measurement, carotid endarterectomy substantially reduces recurrent stroke risk when performed within about 6 months, ideally early after the event. Stenting carries higher periprocedural stroke risk in older patients and is reserved for selected cases such as high surgical risk or restenosis after endarterectomy. Medical therapy alone leaves an unacceptable residual risk at this degree of stenosis.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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