Carotid Stenosis Treatment

Written and medically reviewed by Brian Walcott, MD, board-certified neurosurgeon at Santa Barbara Cottage Hospital. Last updated September 2026.

Understanding Carotid Stenosis

The carotid arteries run up both sides of the neck and carry most of the blood supply to the brain. Over time, cholesterol plaque can build up where the carotid artery divides, narrowing the vessel. This narrowing is called carotid stenosis.

The danger is less about reduced blood flow and more about the plaque itself. Fragments of plaque, or small clots that form on its surface, can break loose and travel into the brain, causing a transient ischemic attack (TIA) or a stroke. Many of these strokes are preventable when carotid disease is recognized and treated.

Many people with carotid stenosis have no symptoms, and the narrowing is found on an ultrasound done for another reason. I recently wrote about how common silent plaque is, even in people who feel healthy. Others are diagnosed after a warning event. That difference, symptomatic versus asymptomatic disease, is the single most important factor in deciding on treatment.

Narrowing can also occur in the arteries inside the skull, called intracranial stenosis. It behaves differently and is managed primarily with intensive medical therapy, with revascularization considered for select patients who continue to have symptoms.

My Approach to Carotid Stenosis

I perform both carotid endarterectomy and carotid artery stenting, and I help each patient choose based on their anatomy, symptoms, and overall health rather than defaulting to one procedure. Some patients are clearly better served by surgery, some by stenting, and many with asymptomatic disease do well with medication and careful follow-up. Every procedure carries risks, including stroke, which I review with you in detail.

For patients who have had a TIA or stroke from a significantly narrowed carotid artery, timing matters. The risk of another stroke is highest in the days and weeks after the first event, and treatment is generally most beneficial when it is performed soon after symptoms, ideally within two weeks when it is safe to do so.

For people without symptoms, the evidence has recently shifted. The CREST-2 trial, published in 2025, found that for severe asymptomatic narrowing, stenting combined with modern medical therapy lowered the risk of stroke compared with medical therapy alone, while endarterectomy did not show a significant added benefit in that trial. The absolute benefit is modest, so the decision remains individual, and I walk through the numbers with each patient.

Treatment Options

Intensive Medical Therapy

Every patient with carotid disease benefits from intensive medical therapy, whether or not a procedure is needed: antiplatelet medication, a high-intensity statin, blood pressure and blood sugar control, and quitting smoking. For many people with asymptomatic stenosis, this is the foundation of treatment.

Carotid Endarterectomy

Endarterectomy is an open operation performed through an incision on the side of the neck. The artery is opened, the plaque is removed directly, and the artery is closed, often with a patch. It has decades of evidence behind it and remains an excellent option, particularly after a TIA or stroke, for older patients, and for plaque or anatomy that is less favorable for a stent. Most patients spend one night in the hospital.

Carotid Artery Stenting

Stenting treats the narrowing from inside the artery. A catheter is guided to the carotid artery, a protection device helps capture debris during the procedure, and a mesh stent is placed to hold the artery open. Stenting avoids a neck incision and is often preferred for patients with prior neck surgery or radiation, a narrowing high in the neck, or heart or lung conditions that raise the risk of open surgery. Patients take two antiplatelet medications for a period afterward.

Surveillance

For mild or moderate narrowing, periodic carotid ultrasound tracks whether the plaque is progressing, so that treatment can be offered at the right time.

Warning Signs of a TIA or Stroke

• Sudden weakness or numbness of the face, arm, or leg, especially on one side
• Sudden difficulty speaking or understanding speech
• Sudden loss of vision in one eye, sometimes described as a shade coming down
• Sudden loss of balance or coordination

Symptoms that resolve within minutes are still an emergency. A TIA is a warning sign. Call 911 immediately.

Why Choose Dr. Walcott for Carotid Stenosis?

• Both Endarterectomy and Stenting: The procedure is chosen for the patient, not the other way around
• Stroke Expertise: Over 500 ischemic strokes treated, with a focus on preventing the next one
• Fellowship Training: Open cerebrovascular surgery (UCSF) and endovascular neurosurgery (USC)
• Harvard and MGH Residency: Neurosurgical training at Massachusetts General Hospital and Harvard Medical School
• Comprehensive Stroke Center: Care at Santa Barbara Cottage Hospital