1. For neurologically symptomatic patients with stenosis <50% or asymptomatic patients with stenosis <60% diameter reduction optimal medical therapy is indicated. There are no data to support either CAS or CEA in this patient group (Grade 1, Level B).
2. In the majority of patients with carotid stenosis who are candidates for intervention, CEA is preferred to CAS for reduction of all cause stroke and periprocedural mortality (Grade 1, Level B). Data from CREST suggest that patients <70 years of age may be better treated by CAS. These data need further confirmation.
3. Neurologically asymptomatic patients with ≥60% diameter stenosis, should be considered for CEA for reduction of long-term risk of stroke provided the patient has a 3-to-5-year life expectancy and perioperative stroke/death rates can be equal to or <3% (Grade 1, Level A).
4. CEA is preferred over CAS in patients >70 years of age, with long (>15 mm) lesions, preocclusive stenosis, or lipid-rich plaques that can be completely removed safely by a cervical incision in patients who have a virgin, nonradiated neck (Grade 1, Level A).
5. CAS is preferred over CEA in symptomatic patients with ≥50% stenosis and prior ipsilateral operation, tracheal stoma, external beam irradiation resulting in fibrosis of the tissues of the ipsilateral neck, or prior cranial nerve injury and lesions that extend proximal to the clavicle or distal to the C2 vertebral body (Grade 2, Level B).
6. CAS is preferred over CEA in symptomatic patients with ≥50% stenosis and severe uncorrectable CAD, CHF, or COPD (Grade 2, Level C). In making this a grade 2 recommendation, the committee recognized the difficulty in clearly defining this group of individuals, both in terms of symptomatology and risk assessment and acknowledged the potential increased role of aggressive medical management as primary therapy in this high risk group.
7. Neurologically asymptomatic patients deemed “high risk” for CEA should be considered for primary medical management. CEA can be considered in these patients only with evidence that perioperative morbidity and mortality is <3%. CAS should not be performed in these patients except as part of an ongoing clinical trial (Grade 1, Level B).
8. There are insufficient data to recommend CAS as primary therapy for neurologically asymptomatic patients with 70% to 99% diameter stenosis. Data from CREST suggest that in properly selected asymptomatic patients, CAS is equivalent to CEA in the hands of experienced interventionalists. Operators and institutions performing CAS must exhibit expertise sufficient to meet the previously established American Heart Association guidelines for treatment of patients with asymptomatic carotid stenosis. Specifically, the combined stroke and death rate must be <3% to ensure benefit for the patient (Grade 2, Level B).