Carotid Artery Disease: What You Need to Know

Finding out you have a narrowing in a carotid artery — the large blood vessels on either side of your neck that carry blood to your brain — can feel alarming. Many people are told this unexpectedly, after a routine physical exam, an imaging study for another reason, or after experiencing a brief neurological symptom. The right next step is to get a thorough evaluation so you fully understand your individual stroke risk and the treatment options available to you.

At UNMH, our neurovascular team — including neurosurgeons, vascular surgeons, neurointerventional specialists, and vascular neurologists — evaluates every patient with carotid disease individually and recommends the approach best suited to your anatomy, health history, and preferences. We offer every treatment option available, including the most advanced minimally invasive approaches.

What Is Carotid Artery Disease?

Your two carotid arteries — one on each side of the neck — are the main suppliers of blood to the brain. Each one divides near the angle of the jaw into the internal carotid artery (which feeds the brain) and the external carotid artery (which supplies the face and scalp). Carotid artery disease occurs when a waxy, fatty substance called plaque builds up inside the wall of the internal carotid artery, causing narrowing — called stenosis.

Plaque buildup is the same process that causes heart attacks. Over time, plaque accumulates, hardens, and gradually narrows the artery. The danger is twofold: the narrowed artery can reduce blood flow to the brain, and — more commonly — pieces of unstable plaque can break off, travel to the brain, and block a smaller artery, causing a stroke or transient ischemic attack (TIA).

Why This Matters:  Carotid artery disease is one of the leading preventable causes of stroke. Strokes caused by carotid disease account for approximately 10 to 15 percent of all ischemic strokes. Many of these strokes are preceded by warning signs — a TIA or minor stroke — that, if recognized and treated quickly, represent an opportunity to prevent a major, disabling event.

Risk factors for developing carotid artery disease include:

• High blood pressure (hypertension): The leading cause — directly damages artery walls and accelerates plaque formation
• Cigarette smoking: Significantly increases risk and is the single most powerful modifiable risk factor for carotid disease progression and stroke
• High cholesterol (hyperlipidemia): Promotes plaque buildup throughout the arterial system
• Diabetes: Damages blood vessel walls and promotes atherosclerosis
• Lifestyle factors: Physical inactivity, obesity, and poor diet
• Age and sex: Risk increases significantly after age 65; men are at higher risk at younger ages, but risk equalizes after menopause in women
• Family history: A parent or sibling with carotid disease or early cardiovascular disease increases your likelihood

Symptomatic vs. Asymptomatic: Why the Distinction Matters

Your Stroke Risk: What the Data Shows

Symptomatic Carotid Stenosis: High Near-Term Risk

Symptomatic carotid disease carries a high short-term stroke risk that makes rapid evaluation and treatment a priority. The North American Symptomatic Carotid Endarterectomy Trial (NASCET) — one of the landmark studies in this field — established that patients with symptomatic stenosis of 70 to 99 percent have a two-year ipsilateral stroke risk of approximately 26 percent on medical therapy alone. The risk is particularly concentrated in the first two weeks after a TIA or minor stroke — often called the 'danger window' — when the risk of a major stroke can reach 10 to 15 percent.

Asymptomatic Carotid Stenosis: Lower but Real Risk

Asymptomatic carotid stenosis carries a lower annual stroke risk than symptomatic disease — approximately 1 to 2 percent per year on optimal medical therapy for high-grade stenosis (70% or greater). However, for patients with severe narrowing, certain plaque features such as ulceration, plaque vulnerability on imaging, or evidence of silent strokes on brain MRI, the risk can be meaningfully higher. This is why the decision about whether to intervene on an asymptomatic carotid artery requires an individualized, evidence-based conversation.

New Evidence — CREST-2 (2025):  The most recent landmark data on asymptomatic carotid stenosis comes from CREST-2 (Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial), published in the New England Journal of Medicine in November 2025.

Treatment Options for Carotid Artery Disease

There are three approaches to managing carotid artery disease: intensive medical therapy, carotid endarterectomy (open surgery), and carotid artery stenting (including a newer technique called TCAR). For most patients, some combination of these approaches will be recommended. The right strategy depends on whether your disease is symptomatic, the degree of narrowing, your overall health and surgical risk, and your anatomy.

At UNMH, all patients with significant carotid disease are discussed by our multidisciplinary cerebrovascular team — including vascular surgery, neurointerventional specialists, and vascular neurology — to ensure you receive the safest and most effective recommendation.

Option 1: Intensive Medical Therapy (For All Patients)

Medical management is the foundation of carotid disease treatment — regardless of whether you also undergo a procedure. It addresses the underlying disease process and reduces the risk of future cardiovascular events throughout the body, not just the brain. Key components include:

• Antiplatelet medication: Antiplatelet agents — typically aspirin, or clopidogrel, or a combination — reduce the risk of clots forming on plaque and traveling to the brain. For patients who have had a recent TIA or minor stroke, short-term dual antiplatelet therapy (two agents together) has been shown to significantly reduce early recurrent stroke risk.
• High-intensity statin therapy: High-intensity statin therapy (such as atorvastatin or rosuvastatin) is essential in all patients with carotid artery disease. Statins slow plaque progression, stabilize existing plaque to make it less likely to rupture, and reduce overall cardiovascular risk. The target LDL cholesterol level is typically below 55-70 mg/dL.
• Blood pressure control: A target blood pressure below 130/80 mmHg is recommended. Poorly controlled hypertension is the most important modifiable driver of carotid disease progression and stroke risk.
• Smoking cessation: Smoking is the single most powerful modifiable risk factor for carotid disease. Quitting reduces plaque progression and stroke risk at any age.
• Lifestyle modification: Diabetes management, weight loss, regular aerobic exercise, and a heart-healthy diet (Mediterranean or DASH diet) all contribute to reducing carotid disease progression.

Medical Therapy as Primary Treatment:  For many patients with asymptomatic carotid stenosis — particularly those with moderate narrowing or those at higher procedural risk — intensive medical therapy alone is the most appropriate initial approach, with regular imaging to monitor for disease progression.

Option 2: Carotid Endarterectomy (CEA) — Open Surgery

Carotid endarterectomy is the time-tested surgical standard for treating significant carotid stenosis. Under general or local anesthesia, a vascular surgeon makes a small incision along the side of the neck, opens the carotid artery, and carefully removes the plaque from inside the vessel wall. The artery is then repaired and closed, restoring full, unobstructed blood flow to the brain.

CEA has been performed for over 60 years and is backed by more long-term outcome data than any other carotid treatment. In experienced hands, it carries a very low risk of perioperative stroke or death and provides durable, long-lasting results. Most patients go home the next day and return to full activity within two to four weeks.

• Symptomatic stenosis: CEA is the preferred treatment for symptomatic carotid stenosis of 50 to 99 percent in patients who are good surgical candidates, particularly when the procedure can be performed within two weeks of the neurological event.
• Asymptomatic stenosis: CEA has historically been recommended for asymptomatic patients with 60 to 99 percent stenosis and low surgical risk. However, the CREST-2 findings (see below) have added important nuance to this recommendation, and the decision now involves a more individualized, shared discussion.
• Potential side effects: Temporary numbness near the incision, hoarseness, or difficulty swallowing from nerve proximity — generally resolves within weeks. Serious complications (stroke, heart attack) are uncommon at high-volume centers.

Option 3: Carotid Artery Stenting (CAS) — Including TCAR

Carotid artery stenting places a small, expandable metal mesh tube (stent) inside the narrowed carotid artery to hold it open and restore blood flow. This is done through a catheter — a thin, flexible tube — guided through the blood vessels to the neck, without a surgical incision in the neck itself. All stenting procedures are performed with an embolic protection device, which acts as a filter to capture any debris dislodged during the procedure before it can travel to the brain.

Traditional Transfemoral CAS

In conventional carotid stenting, the catheter is inserted through the femoral artery in the groin and navigated to the carotid artery. This approach is well-established and effective, particularly for patients who are at higher risk for open surgery. However, the need to navigate through the aorta and the carotid arch can sometimes increase the risk of dislodging plaque during the approach — which is why patient selection and anatomical assessment are important.

TCAR — Transcarotid Artery Revascularization

What Makes TCAR Different:  TCAR (Transcarotid Artery Revascularization) is a newer hybrid technique that combines the safety advantages of open surgery with the minimal invasiveness of stenting. It has rapidly become the preferred stenting approach at many high-volume centers, including UNMH.

In TCAR, a small incision is made at the base of the neck — not in the groin — to directly access the carotid artery. A specialized system is then connected that temporarily reverses blood flow away from the brain during the stenting procedure. This flow reversal is the key innovation: any debris dislodged during stent deployment is carried away from the brain rather than toward it, dramatically reducing the risk of procedural stroke.

Compared to conventional transfemoral stenting, TCAR has shown lower rates of periprocedural stroke in large real-world studies. Compared to CEA, TCAR offers a shorter procedure time, lower rates of cranial nerve injury (which can cause temporary hoarseness or difficulty swallowing), and is well-suited for patients at higher surgical risk — such as those with significant heart or lung disease, prior neck surgery, or unfavorable carotid anatomy for CEA.

• Well-suited for: Patients at elevated surgical risk for CEA (heart disease, severe lung disease, prior radiation to the neck, prior CEA on the same side)
• Also preferred for: Patients with high carotid lesions, previous neck dissection, or anatomy that makes open surgery more complex

Recovery:  Procedure and recovery are similar to CEA in most respects — typically an overnight stay and return to normal activity within one to two weeks

Comparing Your Treatment Options

Carotid Disease Care at UNMH: Our Experience

Outcomes for carotid procedures are directly linked to the volume and experience of the treating team. At UNMH, carotid disease is managed by a dedicated cerebrovascular team that combines vascular surgery, neurointerventional surgery, and vascular neurology — providing the full spectrum of expertise under one roof.

Our Volume & Quality

• New Mexico's only Comprehensive Stroke Center — highest level of Joint Commission certification
• All carotid cases reviewed at multidisciplinary neurovascular conference
• Participation in national vascular quality registries for ongoing outcomes tracking

What We Offer

• Full range of treatment options: CEA, TCAR, transfemoral CAS, and medical management
• Experienced vascular surgeons for CEA and TCAR
• Neurointerventional specialists for CAS
• Vascular neurology for stroke prevention, risk factor management, and TIA evaluation
• Rapid TIA evaluation to reduce early stroke risk before treatment decisions are made
• Surveillance imaging and long-term follow-up program after any carotid procedure