Advances in the treatment of asymptomatic carotid stenosis: from conventional to personalized treatment_CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Authors：

ZHAO Wenjie ,  HU Huanrui ,  YANG Yi

Division of Vascular Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu 610041, P. R. China;

Corresponding?author：

HU Huanrui, Email: huhuanrui@126.com; YANG Yi, Email: yangy@wchscu.cn

Keywords：

asymptomatic carotid artery stenosis; best medical treatment; carotid endarterectomy; transfemoral carotid artery stenting; transcarotid artery revascularization

DOI：

10.7507/1007-9424.202605097

Video：

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Objective Summarize advances in risk assessment and treatment of asymptomatic carotid artery stenosis and provide a reference for risk-stratified management and therapeutic decision-making. Methods A systematic literature review was conducted based on studies of asymptomatic carotid artery stenosis both at home and abroad. Results The management of asymptomatic carotid artery stenosis is shifting from reliance on the degree of stenosis alone to multidimensional assessment integrating clinical characteristics, plaque vulnerability, hemodynamic parameters and biomarkers. Best medical treatment is the cornerstone of treatment for all patients and should be continuously optimized through antiplatelet therapy, stepwise lipid-lowering therapy, risk factor control and lifestyle intervention. In patients with high-risk features for stroke or sufficiently long life expectancy and acceptable perioperative risk, carotid revascularization may be considered based on best medical treatment. At present, there are three main methods for carotid revascularization: carotid endarterectomy has the sufficient evidence in evidence-based medicine, transfemoral carotid artery stenting and transcarotid artery revascularization can be used to treat selected patients. Clinical management should follow a closed-loop pathway of assessment, treatment, and follow-up, incorporating multidisciplinary evaluation and shared decision-making. Conclusions The management of asymptomatic carotid artery stenosis should be based on best medical treatment, and individualized guided by multidimensional risk stratification. Future research should focus on developing risk-prediction and procedural decision-making tools apply to Chinese population and strengthening prospective studies and long-term follow-up.

Citation： ZHAO Wenjie, HU Huanrui, YANG Yi. Advances in the treatment of asymptomatic carotid stenosis: from conventional to personalized treatment. CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY, 2026, 33(8): 1153-1160. doi: 10.7507/1007-9424.202605097 Copy

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2.	Hackam DG. Optimal medical management of asymptomatic carotid stenosis [J]. Stroke, 2021, 52(6): 2191-2198.
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7.	Howard DPJ, Gaziano L, Rothwell PM, et al. Risk of stroke in relation to degree of asymptomatic carotid stenosis: a population-based cohort study, systematic review, and meta-analysis [J]. Lancet Neurol, 2021, 20(3): 193-202.
8.	Skagen K, Skjelland M, Zamani M, et al. Unstable carotid artery plaque: new insights and controversies in diagnostics and treatment [J]. Croat Med J, 2016, 57(4): 311-320.
9.	Porambo ME, DeMarco JK. MR imaging of vulnerable carotid plaque [J]. Cardiovasc Diagn Ther, 2020, 10(4): 1019-1031.
10.	Uchihara Y, Saito K, Motoyama R, et al. Neovascularization from the carotid artery lumen into the carotid plaque confirmed by contrast-enhanced ultrasound and histology [J]. Ultrasound Med Biol, 2023, 49(8): 1798-1803.
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23.	Kim BK, Hong SJ, Lee YJ, et al. Long-term efficacy and safety of moderate-intensity statin with ezetimibe combination therapy versus high-intensity statin monotherapy in patients with atherosclerotic cardiovascular disease (RACING): a randomised, open-label, non-inferiority trial [J]. Lancet, 2022, 400(10349): 380-390.
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33.	Musialek P, Bonati LH, Bulbulia R, et al. Stroke risk management in carotid atherosclerotic disease: a clinical consensus statement of the ESC council on stroke and the ESC working group on aorta and peripheral vascular diseases [J]. Cardiovasc Res, 2025, 121(1): 13-43.
34.	Bushnell C, Kernan WN, Sharrief AZ, et al. 2024 guideline for the primary prevention of stroke: a guideline from the American Heart Association/American Stroke Association [J/OL]. Stroke, 2024, 55(12): e344-e424. doi: 10.1161/str.0000000000000482.
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36.	Naylor R, Rantner B, Ancetti S, et al. Editor’s choice - European Society for Vascular Surgery (ESVS) 2023 clinical practice guidelines on the management of atherosclerotic carotid and vertebral artery disease [J]. Eur J Vasc Endovasc Surg, 2023, 65(1): 7-111.
37.	Korshunov DA, Kulbak VA, Chupin AV. Advisability of carotid endarterectomy in asymptomatic patients [J]. Khirurgiia (Mosk), 2024(3): 45-53.
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39.	Kakisis JD, Antonopoulos CN, Mantas G, et al. Cranial nerve injury after carotid endarterectomy: incidence, risk factors, and time trends [J]. Eur J Vasc Endovasc Surg, 2017, 53(3): 320-335.
40.	Brott TG, Howard G, Lal BK, et al. Medical management and revascularization for asymptomatic carotid stenosis [J]. N Engl J Med, 2026, 394(3): 219-231.
41.	Yang B, Ma Y, Wang T, et al. Carotid endarterectomy and stenting in a Chinese population: safety outcome of the revascularization of extracranial carotid artery stenosis trial [J]. Transl Stroke Res, 2021, 12(2): 239-247.
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46.	向宇威, 胡桓睿, 黃斌, 等. 經頸動脈血運重建治療高危頸動脈狹窄的創新探索 [J]. 中國普外基礎與臨床雜志, 2026, 33(1): 58-62.
47.	Kibrik P, Stonko DP, Alsheekh A, et al. Association of carotid revascularization approach with perioperative outcomes based on symptom status and degree of stenosis among octogenarians [J]. J Vasc Surg, 2022, 76(3): 769-777.
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1. Park MS, Kwon S, Lee MJ, et al. Identification of high risk carotid artery stenosis: a multimodal vascular and perfusion imaging study [J/OL]. Front Neurol, 2019, 10: 765. doi: 10.3389/fneur.2019.00765.
2. Hackam DG. Optimal medical management of asymptomatic carotid stenosis [J]. Stroke, 2021, 52(6): 2191-2198.
3. Onur-Beyaz M, Demir ?, Can-Ata E. Carotid artery screening in high risk asymptomatic individuals: outcomes of 3 000 carotid screening [J]. Cir Cir, 2022, 90(1): 11-16.
4. Chang RW, Tucker LY, Rothenberg KA, et al. Incidence of ischemic stroke in patients with asymptomatic severe carotid stenosis without surgical intervention [J]. JAMA, 2022, 327(20): 1974-1982.
5. Nies KPH, Smits LJM, Kassem M, et al. Emerging role of carotid MRI for personalized ischemic stroke risk prediction in patients with carotid artery stenosis [J/OL]. Front Neurol, 2021, 12: 718438. doi: 10.3389/fneur.2021.718438.
6. Gianopoulos I, Daskalopoulou SS. The journey to improving stroke risk stratification for patients with carotid artery stenosis: from medical management to revascularization [J]. Hellenic J Cardiol, 2026, 88: 73-86.
7. Howard DPJ, Gaziano L, Rothwell PM, et al. Risk of stroke in relation to degree of asymptomatic carotid stenosis: a population-based cohort study, systematic review, and meta-analysis [J]. Lancet Neurol, 2021, 20(3): 193-202.
8. Skagen K, Skjelland M, Zamani M, et al. Unstable carotid artery plaque: new insights and controversies in diagnostics and treatment [J]. Croat Med J, 2016, 57(4): 311-320.
9. Porambo ME, DeMarco JK. MR imaging of vulnerable carotid plaque [J]. Cardiovasc Diagn Ther, 2020, 10(4): 1019-1031.
10. Uchihara Y, Saito K, Motoyama R, et al. Neovascularization from the carotid artery lumen into the carotid plaque confirmed by contrast-enhanced ultrasound and histology [J]. Ultrasound Med Biol, 2023, 49(8): 1798-1803.
11. Strecker C, Krafft AJ, Kaufhold L, et al. Carotid geometry and wall shear stress independently predict increased wall thickness-a longitudinal 3D MRI study in high-risk patients [J/OL]. Front Cardiovasc Med, 2021, 8: 723860. doi: 10.3389/fcvm.2021.723860.
12. Gasbarrino K, Zheng H, Daskalopoulou SS. Circulating sex-specific markers of plaque instability in women and men with severe carotid atherosclerosis [J]. Stroke, 2024, 55(2): 269-277.
13. Huang Z, Cheng XQ, Lu RR, et al. Incremental prognostic value of carotid plaque-RADS over stenosis degree in relation to stroke risk [J]. JACC Cardiovasc Imaging, 2025, 18(1): 77-89.
14. Timmerman N, Galyfos G, Sigala F, et al. The TAXINOMISIS project: a multidisciplinary approach for the development of a new risk stratification model for patients with asymptomatic carotid artery stenosis [J/OL]. Eur J Clin Invest, 2020, 50(12): e13411. doi: 10.1111/eci.13411.
15. 中國血脂管理指南修訂聯合專家委員會. 中國血脂管理指南(2023年) [J]. 中國循環雜志, 2023, 38(3): 237-271.
16. 國家衛生健康委腦卒中防治工程委員會. 中國腦卒中防治指導規范 [M]. 北京: 人民衛生出版社, 2021: 510.
17. 中華醫學會外科學分會血管外科學組. 頸動脈狹窄診治指南 [J]. 中國血管外科雜志(電子版), 2017, 9(3): 169-175.
18. Thiraworawong T, Pathonsmith C. Cilostazol-based dual antiplatelet treatment in ischemic stroke or transient ischemic attack patients with asymptomatic carotid artery disease: a propensity score matching analysis [J/OL]. Front Neurol, 2024, 15: 1362124. doi: 10.3389/fneur.2024.1362124.
19. Neumann FJ, Sousa-Uva M, Ahlsson A, et al. 2018 ESC/EACTS guidelines on myocardial revascularization [J]. Eur Heart J, 2019, 40(2): 87-165.
20. Anand SS, Bosch J, Eikelboom JW, et al. Rivaroxaban with or without aspirin in patients with stable peripheral or carotid artery disease: an international, randomised, double-blind, placebo-controlled trial [J]. Lancet, 2018, 391(10117): 219-229.
21. Mach F, Koskinas KC, Roeters van Lennep JE, et al. Erratum to “2025 focused update of the 2019 ESC/EAS guidelines for the management of dyslipidaemias” [Atherosclerosis, 409, (October 2025), 120479] [J/OL]. Atherosclerosis, 2026, 415: 120703. doi: 10.1016/j.atherosclerosis.2026.120703.
22. Mazzolai L, Teixido-Tura G, Lanzi S, et al. 2024 ESC guidelines for the management of peripheral arterial and aortic diseases [J]. Eur Heart J, 2024, 45(36): 3538-3700.
23. Kim BK, Hong SJ, Lee YJ, et al. Long-term efficacy and safety of moderate-intensity statin with ezetimibe combination therapy versus high-intensity statin monotherapy in patients with atherosclerotic cardiovascular disease (RACING): a randomised, open-label, non-inferiority trial [J]. Lancet, 2022, 400(10349): 380-390.
24. Said S, Dardik A, Ochoa Chaar CI. What are the benefits and drawbacks of statins in carotid artery disease? A perspective review[J]. Expert Rev Cardiovasc Ther, 2023, 21(11): 763-777.
25. 中國卒中學會. 泛血管疾病患者血脂管理專家共識(2025版) [J]. 中華醫學雜志, 2026, 106(6): 504-522.
26. Tenet M, Krishnasastry KV, Manvar-Singh P. Best medical therapy for asymptomatic carotid stenosis: imminent or ineffective? [J]. Ann Vasc Surg, 2025, 113: 294-297.
27. 姜瑞霞. 健康管理對腦卒中高危人群行為習慣的影響研究 [J]. 實用心腦肺血管病雜志, 2020, 28(S2): 144-146.
28. 王小璐, 侯帥, 張一峰, 等. 1990-2019年中國歸因于煙草暴露的缺血性腦卒中疾病負擔及其變化趨勢分析 [J]. 中國循環雜志, 2024, 39(11): 1117-1124.
29. 中華醫學會神經病學分會, 中華醫學會神經病學分會腦血管病學組. 中國缺血性卒中和短暫性腦缺血發作二級預防指南2022 [J]. 中華神經科雜志, 2022, 55(10): 1071-1110.
30. 中華醫學會糖尿病學分會. 中國糖尿病防治指南(2024版) [J]. 中華糖尿病雜志, 2025, 17(1): 16-139.
31. 王梅, 張藝馨, 任航, 等. 1990-2021年中國腦卒中疾病負擔歸因于飲食因素的變化趨勢研究 [J/OL]. 中國衛生統計. (2026-04-09) [2026-05-29]. https://link.cnki.net/urlid/21.1153.r.20260408.1005.002.
32. 高血壓營養和運動指導原則(2024年版) [J]. 國際心血管病雜志, 2025, 52(4): 287-288.
33. Musialek P, Bonati LH, Bulbulia R, et al. Stroke risk management in carotid atherosclerotic disease: a clinical consensus statement of the ESC council on stroke and the ESC working group on aorta and peripheral vascular diseases [J]. Cardiovasc Res, 2025, 121(1): 13-43.
34. Bushnell C, Kernan WN, Sharrief AZ, et al. 2024 guideline for the primary prevention of stroke: a guideline from the American Heart Association/American Stroke Association [J/OL]. Stroke, 2024, 55(12): e344-e424. doi: 10.1161/str.0000000000000482.
35. AbuRahma AF, Avgerinos ED, Chang RW, et al. Society for vascular surgery clinical practice guidelines for management of extracranial cerebrovascular disease [J/OL]. J Vasc Surg, 2022, 75(1S): 4S-22S. doi: 10.1016/j.jvs.2022.03.339.
36. Naylor R, Rantner B, Ancetti S, et al. Editor’s choice - European Society for Vascular Surgery (ESVS) 2023 clinical practice guidelines on the management of atherosclerotic carotid and vertebral artery disease [J]. Eur J Vasc Endovasc Surg, 2023, 65(1): 7-111.
37. Korshunov DA, Kulbak VA, Chupin AV. Advisability of carotid endarterectomy in asymptomatic patients [J]. Khirurgiia (Mosk), 2024(3): 45-53.
38. AbuRahma AF, Avgerinos ED, Chang RW, et al. Society for Vascular Surgery clinical practice guidelines for management of extracranial cerebrovascular disease [J/OL]. J Vasc Surg, 2022, 75(1S): 4S-22S. doi: 10.1016/j.jvs.2021.04.073.
39. Kakisis JD, Antonopoulos CN, Mantas G, et al. Cranial nerve injury after carotid endarterectomy: incidence, risk factors, and time trends [J]. Eur J Vasc Endovasc Surg, 2017, 53(3): 320-335.
40. Brott TG, Howard G, Lal BK, et al. Medical management and revascularization for asymptomatic carotid stenosis [J]. N Engl J Med, 2026, 394(3): 219-231.
41. Yang B, Ma Y, Wang T, et al. Carotid endarterectomy and stenting in a Chinese population: safety outcome of the revascularization of extracranial carotid artery stenosis trial [J]. Transl Stroke Res, 2021, 12(2): 239-247.
42. Aggarwal A, Whitler C, Jain A, et al. Carotid artery stenting versus carotid artery endarterectomy in asymptomatic severe carotid stenosis: an updated meta-analysis [J/OL]. Cureus, 2023, 15(12): e50506. doi: 10.7759/cureus.50506.
43. Ishii D, Horie N. Carotid artery stenting [J]. No Shinkei Geka, 2024, 52(2): 399-406.
44. Bramucci A, Fontana A, Massoni CB, et al. Dual- vs single-layer stents for endovascular treatment of symptomatic and asymptomatic internal carotid artery stenosis [J]. Cardiovasc Revasc Med, 2023, 57: 34-40.
45. Liapis CD, Tzavellas G. The role of transcarotid artery revascularization in symptomatic carotid stenosis [J]. Int Angiol, 2025, 44(4): 316-322.
46. 向宇威, 胡桓睿, 黃斌, 等. 經頸動脈血運重建治療高危頸動脈狹窄的創新探索 [J]. 中國普外基礎與臨床雜志, 2026, 33(1): 58-62.
47. Kibrik P, Stonko DP, Alsheekh A, et al. Association of carotid revascularization approach with perioperative outcomes based on symptom status and degree of stenosis among octogenarians [J]. J Vasc Surg, 2022, 76(3): 769-777.
48. Wu WW, Liang P, O’Donnell TFX, et al. Anatomic eligibility for transcarotid artery revascularization and transfemoral carotid artery stenting [J]. J Vasc Surg, 2019, 69(5): 1452-1460.
49. Bonati LH, Kakkos S, Berkefeld J, et al. European Stroke Organisation guideline on endarterectomy and stenting for carotid artery stenosis [J/OL]. Eur Stroke J, 2021, 6(2): Ⅰ-xlⅦ. doi: 10.1177/23969873211012121.
50. Xin WQ, Li MQ, Li K, et al. Systematic and comprehensive comparison of incidence of restenosis between carotid endarterectomy and carotid artery stenting in patients with atherosclerotic carotid stenosis [J]. World Neurosurg, 2019, 125: 74-86.
51. Shen S, Jiang X, Dong H, et al. Effect of aortic arch type on technical indicators in patients undergoing carotid artery stenting [J]. J Int Med Res, 2019, 47(2): 682-688.
52. Voeks JH, Howard G, Roubin GS, et al. Age and outcomes after carotid stenting and endarterectomy: the carotid revascularization endarterectomy versus stenting trial [J]. Stroke, 2011, 42(12): 3484-3490.
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CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Advances in the treatment of asymptomatic carotid stenosis: from conventional to personalized treatment

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