Carotid Artery Stenosis

Our Specialists for Carotid Artery Stenosis

Carotid disease sits at the intersection of neurology, vascular surgery, and neurosurgery. At UChicago, fellowship-trained neurovascular surgeons perform both open carotid endarterectomy and modern stent-based procedures, and they make the call about which one is right for you based on the actual anatomy of your artery — not a one-size-fits-all protocol.

Issam A. Awad, M.D., M.Sc., FACS

Section Chief, Vascular Neurosurgery

Dr. Awad is Section Chief of Vascular Neurosurgery and a world authority on cerebral cavernous malformations. He discovered the Common Hispanic CCM1 and Ashkenazi Jewish CCM2 mutations and leads the nation's first designated CCM Center of Excellence, with continuous NIH funding since 1998. He has authored more than 400 publications with over 100,000 citations, serves as past President of the Congress of Neurological Surgeons, and is an elected member of the Association of American Physicians. Dr. Awad was recruited to lead UChicago's Neurovascular Surgery Program in 2010 and has performed carotid endarterectomy throughout a cerebrovascular career that has drawn referrals from across the country. If you have complex carotid disease at UChicago — recurrent stenosis, a hostile neck, or tandem intracranial disease — he is one of the surgeons reviewing your imaging.

Sean P. Polster, M.D.

Co-Director, Stroke Center; Safadi Faculty Scholar

Dr. Polster is Co-Director of the Stroke Center and directs the Skull Base & Neurovascular Laboratory at UChicago. He leads the Gut-Brain Axis Laboratory, where he was the first to demonstrate that the gut microbiome modulates the effects of radiosurgery on the neurovascular unit. His work is funded at the NIH NINDS R-level, and he has published in Nature Communications, Blood, Stroke, and the Journal of Neurosurgery. Dr. Polster trained in open cerebrovascular surgery alongside Dr. Awad and manages both symptomatic and asymptomatic carotid stenosis patients in the UChicago neurovascular clinic, taking patients through the full spectrum of medical optimization, endarterectomy, and stent-based revascularization.

Omer Doron, M.D., Ph.D.

Endovascular Neurosurgeon

Dr. Doron is an endovascular neurosurgeon who brought more than 2,500 endovascular procedures with him from his Harvard/MGH fellowship. He performs both catheter-based and open microsurgical treatment of aneurysms, stroke, and vascular malformations, and he is building out thrombectomy capability across UChicago's regional network. He holds a PhD in biomedical engineering from Hebrew University of Jerusalem. Dr. Doron's endovascular training lets him offer transfemoral carotid stenting and TCAR as alternatives to open endarterectomy for patients with hostile neck anatomy, prior radiation, or medical comorbidities that make general anesthesia risky — with the procedure choice driven by the specific features of your plaque and arch.

What Is Carotid Artery Stenosis?

Your carotid arteries are the two large blood vessels in the front of your neck that carry most of the blood supply to your brain. You can feel them pulsing on either side of your windpipe. Over time — and especially if you have high blood pressure, high cholesterol, diabetes, or a history of smoking — cholesterol-rich plaque can build up inside the wall of the carotid artery. When the plaque gets thick enough to narrow the channel the blood flows through, that narrowing is called carotid artery stenosis.

The narrowing itself doesn't usually cause symptoms. What causes trouble is when a fragment of the plaque breaks off and travels up into the brain, or when the plaque's surface cracks and a blood clot forms on top of it. Either of these can block a brain artery and cause a stroke or a transient ischemic attack (TIA) — a warning stroke where the symptoms go away within minutes or hours.

Extracranial carotid disease — meaning narrowing of the carotid in the neck, before it enters the skull — is responsible for roughly 10-15% of all ischemic strokes. That number matters because, unlike many other stroke causes, this one can often be fixed before the big stroke ever happens. Finding the narrowing and treating it correctly is one of the clearest wins in stroke prevention.

What Does It Feel Like?

Most carotid stenosis is silent. People are often surprised to learn their artery is 80% blocked because they felt completely normal. That's why the disease is frequently picked up incidentally — during a neck ultrasound ordered for another reason, during workup for a heart murmur, or when a doctor hears a soft whooshing sound (a bruit) with a stethoscope over the neck.

When carotid stenosis does cause symptoms, the symptoms come from bits of plaque or clot traveling to the brain or the eye. They almost always come on suddenly and usually affect only one side of the body — the side opposite the narrowed artery.

Warning signs of a TIA or stroke from carotid disease

• Sudden weakness or numbness in the face, arm, or leg — usually on one side
• Sudden trouble speaking, slurred speech, or trouble understanding what others are saying
• A sudden shade or curtain pulling down over the vision of one eye (called amaurosis fugax)
• Sudden loss of balance, coordination, or a feeling that the room is spinning
• A sudden severe headache with no clear explanation

If any of these happen — even if they go away in a few minutes — call 911 immediately. A TIA is not a false alarm. It is the single strongest warning sign that a bigger stroke may be coming within days or weeks, and it is the moment when carotid surgery saves the most lives.

How Is It Diagnosed?

The workup usually starts with a carotid duplex ultrasound. It's painless, takes about 30 minutes, and uses sound waves to measure both the diameter of your artery and how fast the blood is moving through it. Faster flow through a tighter spot means more severe stenosis. Ultrasound is excellent as a screening test and is usually the first study ordered.

If the ultrasound shows a significant narrowing — or if the picture is unclear — your team will typically confirm the findings with a second study:

• CT angiography (CTA) of the neck and brain. This gives a detailed 3D map of every artery from your aorta to the top of your head and shows exactly where the plaque is, how long it extends, and whether it has calcium in it. CTA also looks at the arteries inside the brain to make sure a downstream problem isn't being missed.
• MR angiography (MRA). Similar information without radiation, sometimes preferred in younger patients or when contrast dye is a concern.
• Catheter angiography. The gold standard, but invasive. Reserved for cases where the non-invasive imaging is ambiguous or where your surgeon needs to see the blood flow in real time to plan the procedure.

Your doctor will also measure the degree of stenosis as a percentage — how much of the artery's normal diameter has been lost — because that number drives nearly every treatment decision. The standard used in modern trials is the NASCET method, where 70-99% stenosis is considered severe.

Finally, if you've had symptoms, you'll also need brain imaging (usually MRI) to look for evidence of small strokes you may not have noticed, and an evaluation of your heart rhythm and blood pressure to rule out other stroke causes like atrial fibrillation.

Types of Carotid Artery Stenosis

Carotid stenosis is classified two ways — by whether it has caused symptoms and by how tight the narrowing is. Both matter, and together they determine whether you're a candidate for surgery.

Symptomatic vs. asymptomatic

• Symptomatic carotid stenosis. You've had a TIA, a stroke, or sudden monocular vision loss in the past 6 months on the side matching the narrowed artery. Your risk of another stroke over the next two years without treatment is very high — and the benefit of fixing the artery is largest.
• Asymptomatic carotid stenosis. The narrowing was found incidentally and has never caused symptoms. Your annual stroke risk on modern medical therapy alone is much lower — often 1% per year or less — so the decision about whether to operate is more nuanced and depends on your life expectancy, your overall health, and the specific features of the plaque.

By degree of stenosis (NASCET method)

• Mild (under 50%). Surgery is not recommended. The treatment is medical — statin, antiplatelet, blood pressure control, and risk factor management.
• Moderate (50-69%). For symptomatic patients, surgery provides a modest but real benefit and is usually offered. For asymptomatic patients, medical therapy alone is typically the right answer.
• Severe (70-99%). This is where surgery shines. Symptomatic patients have the most to gain. Many asymptomatic patients with tight stenosis, a good life expectancy, and high-risk plaque features are also reasonable surgical candidates.
• Near-occlusion or complete occlusion (100%). Once the artery is fully blocked, opening it surgically generally does not help and may be harmful. Treatment shifts to aggressive medical therapy and protecting the remaining blood flow.

How Is It Treated?

Step 1: Medical therapy — for everyone

Whether or not you end up having surgery, every patient with carotid stenosis needs aggressive medical management. The goal is to stabilize the plaque you already have and keep new plaque from forming.

• High-intensity statin. Statins don't just lower cholesterol — they change the chemistry of the plaque itself and make it less likely to rupture. An LDL target under 70 mg/dL (and often under 55) is the current standard.
• Antiplatelet therapy. Usually aspirin 81 mg daily, sometimes clopidogrel, depending on your history.
• Blood pressure control. Target under 130/80 in most patients.
• Diabetes management, smoking cessation, and exercise. Stopping smoking is the single highest-impact thing you can do for your carotid arteries — the benefit begins within weeks.

Step 2: Choose the right procedure — if you need one

There are three accepted ways to mechanically open a narrowed carotid artery. All three work, but they have different strengths and the choice depends on your anatomy, age, and risk profile.

Carotid endarterectomy (CEA)

CEA is the oldest and best-studied carotid procedure and is still considered the gold standard for most patients with symptomatic severe stenosis. Through a small incision on the side of your neck, the surgeon opens the artery, physically peels the plaque out of the vessel wall, and then either sews the artery closed directly or with a small patch. The operation takes 1-2 hours and most patients go home the next day. The landmark NASCET trial showed that CEA plus medical therapy reduced the 2-year stroke risk in symptomatic patients with 70-99% stenosis by an absolute 17 percentage points compared with medical therapy alone.

Carotid artery stenting (CAS)

In transfemoral CAS, an interventional specialist threads a thin catheter up to the carotid from an artery in the groin (or sometimes the wrist), opens the narrowed segment with a small balloon, and leaves a metal mesh stent in place to hold it open. A filter placed above the stenosis catches any plaque fragments that break loose during the procedure. CAS avoids a neck incision and general anesthesia, which can be an advantage in patients with hostile neck anatomy, prior neck radiation, or severe heart or lung disease that makes open surgery risky.

Transcarotid artery revascularization (TCAR)

TCAR is the newest of the three procedures and is rapidly becoming a preferred alternative to transfemoral stenting. Through a very small incision at the base of the neck, the surgeon exposes the lower (common) carotid artery, attaches a device that temporarily reverses the direction of blood flow in the carotid — pulling any debris away from the brain and filtering it externally — and then places the stent through that same direct access. Because the brain is protected by flow reversal during the entire risky part of the procedure, TCAR has produced some of the lowest periprocedural stroke rates of any stent-based carotid intervention, with outcomes that approach CEA in real-world registries.

How we decide

The short version: symptomatic patients under 70 often do equally well with CEA or stenting. Older patients (especially over 75) generally do better with CEA than with transfemoral stenting because their aortic arch anatomy makes stent delivery riskier — though TCAR narrows that gap considerably. Patients with high-risk anatomy — a prior neck dissection, radiation, contralateral vocal cord paralysis, or a very high stenosis near the skull base — are usually better served by TCAR or stenting. Your team reviews your imaging together and picks the option with the lowest expected risk.

What Are the Outcomes?

Carotid surgery is one of the most durable preventive operations in medicine. When it is done correctly, in the right patient, by an experienced team, it lowers the 5- and 10-year stroke risk dramatically and the benefit is lifelong.

Here is what the major randomized trials have shown:

The big picture

If you have a symptomatic 70-99% stenosis and you're a reasonable surgical candidate, doing nothing is by far the most dangerous option. CEA remains the benchmark: roughly half the 5-year stroke risk compared with medical therapy alone, with a 30-day stroke-or-death rate around 2-3% in experienced hands. CREST and its 10-year follow-up established that CAS and CEA are roughly equivalent in the long run — CEA has slightly more heart attacks in the periprocedural window, and CAS has slightly more minor strokes, but the disabling-stroke and long-term outcomes are similar. TCAR, now widely adopted, has closed the stroke gap for patients who aren't ideal for open surgery.

For asymptomatic patients, the calculus is harder. With modern statins and blood pressure control, the natural-history stroke risk is now low enough that not every 70% stenosis needs an operation. The decision should be made by a team that does these procedures often, reviews your imaging in detail, and can quote you their own outcomes — not just the averages from trials.

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