Extracranial Cerebrovascular Disease

Publication Date: June 18, 2021
Last Updated: April 11, 2023

Summary of Recommendations

1. Asymptomatic carotid stenosis

1.1 For low surgical risk patients with asymptomatic carotid bifurcation atherosclerosis and stenosis of >70% (documented by validated duplex ultrasound or computed tomography angiography [CTA]/angiography), we recommend CEA with best medical therapy instead of maximal medical therapy alone for the long-term prevention of stroke and death. ( 1 – Strong , B)

2. Symptomatic carotid artery stenosis

2.1 We recommend CEA over TF-CAS in low- and standard-risk patients with >50% symptomatic carotid artery stenosis. ( 1 – Strong , A)

3. Management of acute neurologic syndrome

3.1 In patients with recent stable stroke (modified Rankin scale score, 0-2), we recommend carotid revascularization for symptomatic patients with >50% stenosis to be performed as soon as the patient is neurologically stable after 48 hours but definitely before 14 days after the onset of symptoms. ( 1 – Strong , B)
3.2 In patients undergoing revascularization within the first 14 days after the onset of symptoms, we recommend CEA rather than carotid stenting. ( 1 – Strong , B)
3.3 We recommend against revascularization, regardless of the extent of stenosis for patients who experienced a disabling stroke, have a modified Rankin scale score of ≥3, whose area of infarction is >30% of the ipsilateral middle cerebral artery territory, or who have altered consciousness to minimize the risk of postoperative parenchymal hemorrhage. ( 1 – Strong , C)
These patients can be reevaluated for revascularization later if their neurologic recovery is satisfactory.

4. Screening

4.1 We recommend against the routine screening for clinically asymptomatic carotid artery stenosis for individuals without cerebrovascular symptoms or significant risk factors for carotid artery disease. ( 1 – Strong , B)
4.2 In selected asymptomatic patients who are at an increased risk of carotid stenosis, we suggest screening for clinically asymptomatic carotid artery stenosis, especially if patients are willing to consider carotid intervention if significant stenosis is discovered. ( 2 – Weak , B)
4.3 In asymptomatic patients who are undergoing screening for carotid artery stenosis, we recommend duplex ultrasound performed in an accredited vascular laboratory as the imaging modality of choice instead of CTA, MRA, or other imaging modalities. ( 1 – Strong , B)

5. Combined carotid artery stenosis and coronary artery disease

5.1. For patients with symptomatic carotid stenosis of 50% to 99%, who require both CEA and CABG, we suggest CEA before, or concomitant with, CABG to potentially reduce the risk of stroke and stroke/death. The sequencing of the intervention depends on the clinical presentation and institutional experience. ( 2 – Weak , C)
5.2. In patients with severe (70%-99%) bilateral asymptomatic carotid stenosis or severe asymptomatic stenosis and contralateral occlusion, we suggest CEA before or concomitant with CABG. ( 2 – Weak , C)
5.3 In patients requiring carotid intervention, staged or synchronous with coronary intervention, we suggest that the decision between CEA and CAS be determined by the timing of the procedure, the need for anticoagulation or antiplatelet therapy, patient anatomy, and patient characteristics. ( 2 – Weak , B)

Recommendation Grading


The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.



Extracranial Cerebrovascular Disease

Authoring Organization

Publication Month/Year

June 18, 2021

Last Updated Month/Year

February 9, 2024

Document Type


Country of Publication


Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Ambulatory, Emergency care, Hospital

Intended Users

Nurse, nurse practitioner, physician, physician assistant



Diseases/Conditions (MeSH)

D020521 - Stroke, D002561 - Cerebrovascular Disorders, D002560 - Cerebrovascular Circulation, D002340 - Carotid Artery Diseases


carotid stenosis, Stroke Prevention, carotid bifurcation stenosis, extracranial cerebrovascular disease, endarterectomy, asymptomatic carotid stenosis, symptomatic carotid artery stenosis, acute neurologic syndrome

Source Citation

AbuRahma AF, Avgerinos E(M), Chang RW, Darling III RC, Duncan AA, Forbes TL, et al., Society for Vascular Surgery clinical practice guidelines for management of extracranial cerebrovascular disease, Journal of Vascular Surgery (2021), doi: 10.1016/j.jvs.2021.04.073.

AbuRahma AF, Avgerinos E(M), Chang RW, Darling III RC, Duncan AA, Forbes TL, et al., Society for Vascular Surgery implementation document for management of extracranial cerebrovascular disease. Journal of Vascular Surgery (2021), doi: 10.1016/j.jvs.2021.04.074