Recent Advances and Controversial Issues in the Optimal Management of Asymptomatic Carotid Stenosis

Objective: The optimal management of patients with asymptomatic carotid stenosis (AsxCS) is enduringly controversial. We updated our 2021 Expert Review and Position Statement, focusing on recent advances in the diagnosis and management of AsxCS patients. Methods: A systematic review of the literature was performed up to August 1, 2023, using PubMed/PubMed Central, EMBASE and Scopus. The following keywords were used in various combinations: "asymptomatic carotid stenosis", "carotid endarterectomy" (CEA), "carotid artery stenting" (CAS) and "transcarotid artery revascularization" (TCAR). Areas covered included: i) improvements in best medical treatment (BMT) for AsxCS patients and declining stroke risk, ii) technological advances in surgical/endovascular skills/techniques and outcomes, iii) risk factors, clinical/imaging characteristics and risk prediction models for the identification of high-risk AsxCS patient subgroups, and, iv) the association between cognitive dysfunction and AsxCS. Results: BMT is essential for all AsxCS patients, regardless of whether they will eventually be offered CEA/CAS/TCAR. Specific patient subgroups at high risk for stroke despite BMT should be considered for a carotid revascularization procedure. These include patients with severe (≥80%) AsxCS, transcranial Doppler-detected microemboli, plaque echolucency on Duplex ultrasound, silent infarcts on brain CTA/MRA scans, reduced cerebrovascular reserve, increased size of juxtaluminal hypoechoic area, AsxCS progression, carotid plaque ulceration and intraplaque hemorrhage. Treatment of AsxCS patients should be individualized, taking into consideration individual patient preferences/needs, clinical/imaging characteristics, and cultural/ethnic/social factors. Solid evidence supporting/refuting an association between AsxCS and cognitive dysfunction is lacking. Conclusions: The optimal management of AsxCS patients should include BMT for all individuals and a prophylactic carotid revascularization procedure (CEA/CAS/TCAR) for some asymptomatic patient subgroups, additionally taking into consideration individual patient needs/preference, clinical/imaging characteristics, social/cultural factors and the available stroke risk prediction models. Future studies should investigate the association between AsxCS with cognitive function and the role of carotid revascularization procedures in the progression/reversal of cognitive dysfunction