A shift of treatment approaches in internal carotid artery stenosis

The purpose of this review is to objectively present and discuss the scientific literature that is critical for decision-making on the optimal choice of prevention and treatment method for patients with atherosclerotic stenosis of the internal carotid artery (ICA). The evolution of approaches to the treatment of the disease over the past 3–4 decades is analyzed. A summary of the evidence base regarding the efficacy and safety of surgical and drug methods for the prevention and treatment of stroke in symptomatic and asymptomatic patients with ICA stenosis is provided. Conclusions are made regarding the current priorities in the choice of stroke prevention and treatment in patients with ICA stenosis. The review analyzes current randomized trials and explains why they are unlikely to determine routine indications for carotid artery procedures. Previous randomized trials have shown the effectiveness of carotid endarterectomy in reducing the risk of stroke. However, not all patients benefit from the procedure, especially asymptomatic patients. In any given patient, it is usually impossible to be certain of the cause of stroke or transient ischemic attack. Relevant global recommendations for carotid artery procedures, including ways to improve them, are discussed. Conclusion: The cornerstone of stroke prevention is optimal medical therapy, as this procedure is noninvasive and protects against all complications of atherosclerosis in various vascular beds in all at-risk individuals. The important question remains whether carotid surgery is beneficial to the patient in the modern era, and if so, for whom?