A 70-year-old man presents with a 2-month history of left-sided amaurosis fugax and a right-sided hemispheric TIA. Duplex ultrasound shows an 80% stenosis of the right internal carotid artery at the bifurcation. He is on aspirin 75 mg and a statin. He has no significant surgical comorbidity. What is the recommended intervention to reduce his future stroke risk?
- A Carotid artery stenting (CAS) as a first-line procedure
- B Intensify antiplatelet therapy to dual antiplatelet (aspirin + clopidogrel) and review in 6 months
- C Carotid endarterectomy within 2 weeks of the index TIA ✓
- D Anticoagulation with warfarin and repeat duplex in 3 months
Explanation
For a symptomatic significant carotid stenosis (70–99% by NASCET criteria), carotid endarterectomy (CEA) is the most effective intervention to reduce ipsilateral stroke risk, with the greatest benefit when performed early — within 2 weeks of the TIA/minor stroke, when the stroke risk is highest. Delaying surgery beyond 2 weeks substantially reduces the absolute benefit. The NASCET and ECST trials demonstrated that CEA combined with best medical therapy is markedly superior to medical therapy alone for symptomatic 70–99% stenosis. Carotid stenting (CAS) is an alternative mainly for patients who are high surgical risk or have unfavourable anatomy. Dual antiplatelet and anticoagulation alone are insufficient for high-grade symptomatic carotid disease.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
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Written and medically reviewed by the StethoPrep medical team.