SRS273 - Carotid Web—CEA remains the only mainstay treatment for symptomatic webs

Abstract Introduction Carotid web is an under-recognized vascular anomaly implicated in cryptogenic stroke, particularly in younger patients. It appears as a shelf-like projection in the proximal internal carotid artery (ICA), promoting thrombus formation and embolism. Missed diagnosis results in disabling or fatal strokes. Optimal management remains debated. Methods We retrospectively reviewed patients diagnosed with carotid web at our center from 2010 to 2025. CT angiograms were analyzed for morphology and correlated with clinical presentation, including transient ischemic attack (TIA) and stroke. Both symptomatic and incidental cases were included, with focus on recurrence. Outcomes were compared between best medical therapy (BMT) and surgical or endovascular intervention. Results A total of 134 patients were identified (mean age 65, range 32–92; female 59%, n = 79). Just over half were symptomatic (58.2%, n = 78); among these, 39.7% (n = 31/78) experienced recurrent neurological events despite BMT. Most patients were treated conservatively (92.5%, n = 124): 77.4% (n = 96/124) with antiplatelets and 22.6% (n = 28/124) anticoagulated. Recurrence was highest with antiplatelets; anticoagulation failed in 17.9% (n = 5/28). Intervention was performed in 9 patients (6.7%): 8 carotid endarterectomies (CEA) and 1 stent. All were for recurrent events (29.0%, n = 9/31 of recurrent subgroup). No recurrences occurred post-surgery. Conclusions Carotid web carries a high recurrence risk; nearly 40% of symptomatic patients relapse despite BMT. Antiplatelets and anticoagulation are inadequate. CEA eliminates the embolic source and achieved zero recurrences. Early recognition and proactive surgical intervention should be considered the mainstay of treatment.