Chinese Expert Consensus on Neurointerventional Diagnosis and Treatment of Carotid Artery Calcification Lesions

doi:10.3969/j.issn.1673-5765.2025.10.010

Abstract

Abstract: The Chinese Expert Consensus on Neurointerventional Diagnosis and Treatment of Carotid Artery Calcification Lesions was developed by experts organized jointly by the Pan-Vascular Disease Branch of Beijing Neurology Society and Chinese Interventional Neuroradiology Society of Chinese Stroke Association, based on the latest advances and evidence-based medical data in the diagnosis and treatment of carotid artery calcification lesions. This consensus comprehensively outlines the epidemiological characteristics, pathological mechanisms, and multi-modal imaging assessment methods (including carotid ultrasound, CTA, MRA, DSA, and optical coherence tomography) for carotid artery calcification lesions, and establishes quantitative criteria for the degree of arterial stenosis. For treatment, the consensus not only discusses strategies such as non-surgical management, carotid endarterectomy, and transcarotid artery revascularization but also specifically standardizes key aspects of carotid artery stenting. These include its indications, contraindications, procedural timing, procedural steps, stent selection, perioperative management, and long-term postoperative follow-up. The consensus aims to establish a standardized neurointerventional framework for clinicians, improve the treatment outcomes and prognosis these patients, reduce their cardiovascular and cerebrovascular risks, and serve as a vital reference for healthcare professionals, social workers, government agencies, healthcare administrators, and pharmaceutical enterprises.

Key words: Carotid artery calcification lesion; Multi-modal imaging examination; Carotid artery stenting; Perioperative management; Consensus

摘要： 《颈动脉钙化病变神经介入诊疗中国专家共识》由北京神经内科学会泛血管病分会联合中国卒中学会神经介入分会组织专家，基于当前颈动脉钙化病变诊疗的最新进展和循证医学证据编写。本共识详细阐述了颈动脉钙化病变的流行病学特征、病理机制及多模态影像学评估方法（如颈动脉超声、CTA、MRA、DSA及光学相干断层扫描），明确了动脉狭窄程度的量化标准。在治疗方面，本共识不仅讨论了非手术治疗、颈动脉内膜切除术、经颈动脉血运重建术等策略，还重点规范了颈动脉支架成形术的适应证、禁忌证、手术时机、手术步骤、支架选择、围手术期管理及长期随访方案等关键内容。本共识旨在为临床医师提供颈动脉钙化病变的规范化神经介入诊疗框架，以期改善此类患者的治疗效果和预后，降低其心脑血管事件风险，并为相关专业人员、社会工作者、政府管理机构、卫生事业管理人员、医药企业等提供参考和指导。

关键词: 颈动脉钙化病变; 多模态影像学检查; 颈动脉支架成形术; 围手术期管理; 共识

CLC Number:

Expert Group of Chinese Expert Consensus on Neurointerventional Diagnosis and Treatment of Carotid Artery Calcification Lesions, Pan-Vascular Disease Branch of Beijing Neurology Society, Chinese Interventional Neuroradiology Society of Chinese Stroke Association. Chinese Expert Consensus on Neurointerventional Diagnosis and Treatment of Carotid Artery Calcification Lesions[J]. Chinese Journal of Stroke, 2025, 20(10): 1277-1294.

《颈动脉钙化病变神经介入诊疗中国专家共识》工作组, 北京神经内科学会泛血管病分会, 中国卒中学会神经介入分会. 颈动脉钙化病变神经介入诊疗中国专家共识[J]. 中国卒中杂志, 2025, 20(10): 1277-1294.

References

[1] 《中国脑卒中防治报告2021》编写组. 《中国脑卒中防治报告2021》概要[J]. 中国脑血管病杂志，2023，20（11）：783-792，封3.
Report on Stroke Prevention and Treatment in China Writing Group. Brief report on stroke prevention and treatment in China，2021[J]. Chin J Cerebrovasc Dis，2023，20（11）：783-792，inside back cover 3.
[2] CHENG S F，BROWN M M，SIMISTER R J，et al. Contemporary prevalence of carotid stenosis in patients presenting with ischaemic stroke[J]. Br J Surg，2019，106（7）：872-878.
[3] BONATI L H，JANSEN O，DE BORST G J，et al. Management of atherosclerotic extracranial carotid artery stenosis[J]. Lancet Neurol，2022，21（3）：273-283.
[4] MEHTA A，RIGDON J，TATTERSALL M C，et al. Association of carotid artery plaque with cardiovascular events and incident coronary artery calcium in individuals with absent coronary calcification：the MESA[J/OL]. Circ Cardiovasc Imaging，2021，14（4）：e011701[2025-02-25]. https://doi.org/10.1161/CIRCIMAGING.120.011701.
[5] KOZÀKOVÀ M，PALOMBO C，MORIZZO C，et al. Gender-specific differences in carotid intima-media thickness and its progression over three years：a multicenter European study[J]. Nutr Metab Cardiovasc Dis，2013，23（2）：151-158.
[6] SONG P G，XIA W，ZHU Y J，et al. Prevalence of carotid atherosclerosis and carotid plaque in Chinese adults：a systematic review and meta-regression analysis[J/OL]. Atherosclerosis，2018，276：67-73[2025-02-25]. https://doi.org/10.1016/j.atherosclerosis.2018.07.020.
[7] JOH J H，CHO S. Cardiovascular risk of carotid atherosclerosis：global consensus beyond societal guidelines[J/OL]. Lancet Glob Health，2020，8（5）：e625-e626[2025-02-25]. https://doi.org/10.1016/S2214-109X(20)30132-7.
[8] 《老年人颈动脉粥样硬化性疾病诊治中国专家建议》写作组，中华医学会老年医学分会，《中华老年医学杂志》编辑委员会. 老年人颈动脉粥样硬化性疾病诊治中国专家建议[J]. 中华老年医学杂志，2013，32（2）：113-120.
Writing Group of Chinese Expert Consensus on Diagnosis and Treatment of Carotid Atherosclerotic Disease in the Elderly，Geriatrics Branch of Chinese Medical Association，Editorial Board of Chinese Journal of Geriatrics. Chinese expert consensus on diagnosis and treatment of carotid atherosclerotic disease in the elderly[J]. Chin J Geriatr，2013，32（2）：113-120.
[9] LIBBY P. Role of inflammation in atherosclerosis associated with rheumatoid arthritis[J/OL]. Am J Med，2008，121（10 Suppl 1）：S21-S31[2025-02-25]. https://doi.org/10.1016/j.amjmed.2008.06.014.
[10] LIBBY P，RIDKER P M，MASERI A. Inflammation and atherosclerosis[J]. Circulation，2002，105（9）：1135-1143.
[11] ROSS R. Atherosclerosis—an inflammatory disease[J]. N Engl J Med，1999，340（2）：115-126.
[12] NISHIMURA R A，OTTO C M，BONOW R O，et al. 2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for the management of patients with valvular heart disease：a report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines[J]. J Am Coll Cardiol，2017，70（2）：252-289.
[13] FUERY M A，LIANG L S，KAPLAN F S，et al. Vascular ossification：pathology，mechanisms，and clinical implications[J/OL]. Bone，2018，109：28-34[2025-02-25]. https://doi.org/10.1016/j.bone.2017.07.006.
[14] DHARMAKIDARI S，BHATTACHARYA P，CHATURVEDI S. Carotid artery stenosis：medical therapy，surgery，and stenting[J/OL]. Curr Neurol Neurosci Rep，2017，17（10）：77[2025-02-25]. https://doi.org/10.1007/s11910-017-0786-2.
[15] ARNETT D K，BLUMENTHAL R S，ALBERT M A，et al. 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease：a report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines[J/OL]. Circulation，2019，140（11）：e596-e646[2025-02-25]. https://doi.org/10.1161/CIR.0000000000000678.
[16] BARNETT H J，TAYLOR D W，ELIASZIW M，et al. Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis[J]. N Engl J Med，1998，339（20）：1415-1425.
[17] European Carotid Surgery Trialists’ Collaborative Group. Randomised trial of endarterectomy for recently symptomatic carotid stenosis：final results of the MRC European carotid surgery trial（ECST）[J]. Lancet，1998，351（9113）：1379-1387.
[18] SABA L，NARDI V，CAU R，et al. Carotid artery plaque calcifications：lessons from histopathology to diagnostic imaging[J]. Stroke，2022，53（1）：290-297.
[19] DE WAARD D，DE BORST G J，BULBULIA R，et al. Pre-operative carotid plaque echolucency assessment has no predictive value for long-term risk of stroke or cardiovascular death in patients undergoing carotid endarterectomy[J]. Eur J Vasc Endovasc Surg，2017，54（2）：135-141.
[20] MURRAY C S G，NAHAR T，KALASHYAN H，et al. Ultrasound assessment of carotid arteries：current concepts，methodologies，diagnostic criteria，and technological advancements[J]. Echocardiography，2018，35（12）：2079-2091.
[21] NEDERKOORN P J，VAN DER GRAAF Y，HUNINK M G M. Duplex ultrasound and magnetic resonance angiography compared with digital subtraction angiography in carotid artery stenosis：a systematic review[J]. Stroke，2003，34（5）：1324-1332.
[22] DE MONYÉ C，DE WEERT T T，ZAALBERG W，et al. Optimization of CT angiography of the carotid artery with a 16-MDCT scanner：craniocaudal scan direction reduces contrast material-related perivenous artifacts[J]. AJR Am J Roentgenol，2006，186（6）：1737-1745.
[23] AGATSTON A S，JANOWITZ W R，HILDNER F J，et al. Quantification of coronary artery calcium using ultrafast computed tomography[J]. J Am Coll Cardiol，1990，15（4）：827-832.
[24] KUYA K，SHINOHARA Y，KATO A，et al. Reduction of metal artifacts due to dental hardware in computed tomography angiography：assessment of the utility of model-based iterative reconstruction[J]. Neuroradiology，2017，59（3）：231-235.
[25] LI Y Y，WANG J D. Contrast-induced acute kidney injury：a review of definition，pathogenesis，risk factors，prevention and treatment[J/OL]. BMC Nephrol，2024，25：140[2025-02-25]. https://doi.org/10.1186/s12882-024-03570-6.
[26] KRAMER H，RUNGE V M，MORELLI J N，et al. Magnetic resonance angiography of the carotid arteries：comparison of unenhanced and contrast enhanced techniques[J]. Eur Radiol，2011，21（8）：1667-1676.
[27] MEISSNER B，KALLENBERG K，SANCHEZ-JUAN P，et al. Isolated cortical signal increase on MR imaging as a frequent lesion pattern in sporadic Creutzfeldt-Jakob disease[J]. AJNR Am J Neuroradiol，2008，29（8）：1519-1524.
[28] PESCHKE E，ULLOA P，JANSEN O，et al. Metallic implants in MRI—hazards and imaging artifacts[J]. Rofo，2021，193（11）：1285-1293.
[29] WARDLAW J M，STEVENSON M D，CHAPPELL F，et al. Carotid artery imaging for secondary stroke prevention：both imaging modality and rapid access to imaging are important[J]. Stroke，2009，40（11）：3511-3517.
[30] TEARNEY G J，REGAR E，AKASAKA T，et al. Consensus standards for acquisition，measurement，and reporting of intravascular optical coherence tomography studies：a report from the International Working Group for Intravascular Optical Coherence Tomography Standardization and Validation[J]. J Am Coll Cardiol，2012，59（12）：1058-1072.
[31] FAROOQ M U，KHASNIS A，MAJID A，et al. The role of optical coherence tomography in vascular medicine[J]. Vasc Med，2009，14（1）：63-71.
[32] WOODCOCK R J，Jr，GOLDSTEIN J H，KALLMES D F，et al. Angiographic correlation of CT calcification in the carotid siphon[J]. AJNR Am J Neuroradiol，1999，20（3）：495-499.
[33] SUBEDI D，ZISHAN U S，CHAPPELL F，et al. Intracranial carotid calcification on cranial computed tomography：visual scoring methods，semiautomated scores，and volume measurements in patients with stroke[J]. Stroke，2015，46（9）：2504-2509.
[34] KOCKELKOREN R，VOS A，VAN HECKE W，et al. Computed tomographic distinction of intimal and medial calcification in the intracranial internal carotid artery[J/OL]. PLoS One，2017，12（1）：e0168360[2025-02-25]. https://doi.org/10.1371/journal.pone.0168360.
[35] KERNAN W N，OVBIAGELE B，BLACK H R，et al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack：a guideline for healthcare professionals from the American Heart Association/American Stroke Association[J]. Stroke，2014，45（7）：2160-2236.
[36] 中华医学会外科学分会血管外科学组. 颈动脉狭窄诊治指南[J]. 中国血管外科杂志（电子版），2017，9（3）：169-175.
Vascular Surgery Group of Surgery Society of Chinese Medical Association. Guidelines for the diagnosis and treatment of carotid artery stenosis[J]. Chin J Vasc Surg（Electronic Version），2017，9（3）：169-175.
[37] JONSSON M，GILLGREN P，WANHAINEN A，et al. Peri-procedural risk with urgent carotid artery stenting：a population based Swedvasc study[J]. Eur J Vasc Endovasc Surg，2015，49（5）：506-512.
[38] ARASU R，ARASU A，MULLER J. Carotid artery stenosis：an approach to its diagnosis and management[J]. Aust J Gen Pract，2021，50（11）：821-825.
[39] COELHO A，PEIXOTO J，MANSILHA A，et al. Timing of carotid intervention in symptomatic carotid artery stenosis：a systematic review and meta-analysis[J]. Eur J Vasc Endovasc Surg，2022，63（1）：3-23.
[40] GUPTA R，HOROWITZ M，JOVIN T G. Hemodynamic instability after carotid artery angioplasty and stent placement：a review of the literature[J/OL]. Neurosurg Focus，2005，18（1）：e6[2025-02-25]. https://doi.org/10.3171/foc.2005.18.1.7.
[41] TROCCIOLA S M，CHAER R A，LIN S C，et al. Analysis of parameters associated with hypotension requiring vasopressor support after carotid angioplasty and stenting[J]. J Vasc Surg，2006，43（4）：714-720.
[42] RUZSA Z，NEMES B，PINTÉR L，et al. A randomised comparison of transradial and transfemoral approach for carotid artery stenting：RADCAR（radial access for carotid artery stenting）study[J]. EuroIntervention，2014，10（3）：381-391.
[43] MENDIZ O A，FAVA C，LEV G，et al. Transradial versus transfemoral carotid artery stenting：a 16-year single-center experience[J]. J Interv Cardiol，2016，29（6）：588-593.
[44] GIANNAKOPOULOS T G，MOULAKAKIS K，SFYROERAS G S，et al. Association between plaque echogenicity and embolic material captured in filter during protected carotid angioplasty and stenting[J]. Eur J Vasc Endovasc Surg，2012，43（6）：627-631.
[45] WODARG F，TURNER E L，DOBSON J，et al. Influence of stent design and use of protection devices on outcome of carotid artery stenting：a pooled analysis of individual patient data[J]. J Neurointerv Surg，2018，10（12）：1149-1154.
[46] DOIG D，TURNER E L，DOBSON J，et al. Predictors of stroke，myocardial infarction or death within 30 days of carotid artery stenting：results from the international carotid stenting study[J]. Eur J Vasc Endovasc Surg，2016，51（3）：327-334.
[47] KNAPPICH C，KUEHNL A，TSANTILAS P，et al. The use of embolic protection devices is associated with a lower stroke and death rate after carotid stenting[J]. JACC Cardiovasc Interv，2017，10（12）：1257-1265.
[48] HICKS C W，NEJIM B，OBEID T，et al. Use of a primary carotid stenting technique does not affect perioperative outcomes[J]. J Vasc Surg，2018，67（6）：1736-1743.
[49] ZIAPOUR B，SCHERMERHORN M L，IAFRATI M D，et al. A systematic review and meta-analysis of predilation and postdilation in transfemoral carotid artery stenting[J]. J Vasc Surg，2020，72（1）：346-355.
[50] 唐骁，唐涵斐，符伟国，等. 颈动脉硬化狭窄腔内治疗中钙化病变的处理与临床结局[J]. 中华普通外科杂志，2022，37（3）：175-179.
TANG X，TANG H F，FU W G，et al. Clinical outcomes of severe calcified lesions after carotid artery stenting[J]. Chin J Gen Surg，2022，37（3）：175-179.
[51] DILOSA K，SCHONEFELD S，EL-KHOURY R，et al. Multi-center experience with intravascular lithotripsy for treatment of severe calcification during transcarotid artery revascularization for high-risk patients[J]. J Vasc Surg，2024，80（3）：757-763.
[52] GIANNAKOPOULOS S，SPEZIALE F，VADALÀ G，et al. Intravascular lithotripsy for treatment of calcified lesions during carotid artery stenting[J]. J Endovasc Ther，2021，28（1）：93-99.
[53] BAIU I，STERN J R. Carotid artery stenting[J/OL]. JAMA，2020，324（16）：1690[2025-02-25]. https://doi.org/10.1001/jama.2020.10426.
[54] LIN P H，BUSH R L，LUMSDEN A B. Carotid artery stenting：current status and future directions[J]. Vasc Endovascular Surg，2003，37（5）：315-322.
[55] BOSIERS M，DELOOSE K，CALLAERT J，et al. Impact of stent design on outcomes of carotid stent angioplasty[J]. Semin Vasc Surg，2018，31（1）：4-8.
[56] BROTT T G，HALPERIN J L，ABBARA S，et al. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease：executive summary[J]. Vasc Med，2011，16（1）：35-77.
[57] BROTT T G，HOBSON R W，2nd，HOWARD G，et al. Stenting versus endarterectomy for treatment of carotid-artery stenosis[J]. N Engl J Med，2010，363（1）：11-23.
[58] LAMANNA A，MAINGARD J，BARRAS C D，et al. Carotid artery stenting：current state of evidence and future directions[J]. Acta Neurol Scand，2019，139（4）：318-333.
[59] 中华医学会放射学分会介入学组. 颈动脉狭窄介入治疗操作规范（专家共识）[J]. 中华放射学杂志，2010，44（9）：995-998.
Interventional Expert Group of Radiology Branch of Chinese Medical Association. Expert consensus on technical specifications for endovascular treatment of carotid artery stenosis[J]. Chin J Radiol，2010，44（9）：995-998.
[60] MALAS M B，LEAL J，KASHYAP V，et al. Technical aspects of transcarotid artery revascularization using the ENROUTE transcarotid neuroprotection and stent system[J]. J Vasc Surg，2017，65（3）：916-920.
[61] NAYLOR R，RANTNER B，ANCETTI S，et al. European Society for Vascular Surgery（ESVS）2023 clinical practice guidelines on the management of atherosclerotic carotid and vertebral artery disease[J]. Eur J Vasc Endovasc Surg，2023，65（1）：7-111.
[62] WHELTON P K，CAREY R M，ARONOW W S，et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention，detection，evaluation，and management of high blood pressure in adults：executive summary：a report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines[J]. Hypertension，2018，71（6）：1269-1324.
[63] 中国高血压防治指南修订委员会，高血压联盟（中国），中国医疗保健国际交流促进会高血压病学分会，等. 中国高血压防治指南（2024年修订版）[J]. 中华高血压杂志（中英文），2024，32（7）：603-700.
Writing Group of 2018 Chinese Guidelines for the Management of Hypertension，Chinese Hypertension League，Hypertension Branch of China International Exchange and Promotive Association for Medical and Health Care，et al. 2024 Chinese guidelines for the management of hypertension[J]. Chin J Hypertens，2024，32（7）：603-700.
[64] 中华医学会糖尿病学分会. 中国2型糖尿病防治指南（2017年版）[J]. 中华糖尿病杂志，2018，10（1）：4-67.
Chinese Diabetes Society. Chinese guidelines for the prevention and treatment of type 2 diabetes（2017 edition）[J]. Chin J Diabetes Mellitus，2018，10（1）：4-67.
[65] PALMER S C，TENDAL B，MUSTAFA R A，et al. Sodium-glucose cotransporter protein-2（SGLT-2）inhibitors and glucagon-like peptide-1（GLP-1）receptor agonists for type 2 diabetes：systematic review and network meta-analysis of randomised controlled trials[J/OL]. BMJ，2021，372：m4573[2025-02-25]. https://doi.org/10.1136/bmj.m4573.
[66] MACH F，BAIGENT C，CATAPANO A L，et al. 2019 ESC/EAS guidelines for the management of dyslipidaemias：lipid modification to reduce cardiovascular risk[J]. Eur Heart J，2020，41（1）：111-188.
[67] SABATINE M S，GIUGLIANO R P，KEECH A C，et al. Evolocumab and clinical outcomes in patients with cardiovascular disease[J]. N Engl J Med，2017，376（18）：1713-1722.
[68] SAFIAN R D. Asymptomatic carotid artery stenosis：revascularization[J]. Prog Cardiovasc Dis，2017，59（6）：591-600.
[69] GURM H S，YADAV J S，FAYAD P，et al. Long-term results of carotid stenting versus endarterectomy in high-risk patients[J]. N Engl J Med，2008，358（16）：1572-1579.
[70] LAMBA N，ZENONOS G A，IGAMI NAKASSA A C，et al. Long-term outcomes after carotid endarterectomy：the experience of an average-volume surgeon[J/OL]. World Neurosurg，2018，118：e52-e58[2025-02-25]. https://doi.org/10.1016/j.wneu.2018.06.120.
[71] STILO F，MONTELIONE N，CALANDRELLI R，et al. The management of carotid restenosis：a comprehensive review[J/OL]. Ann Transl Med，2020，8（19）：1272[2025-02-25]. https://doi.org/10.21037/atm-20-963.
[72] WHITE C J，BROTT T G，GRAY W A，et al. Carotid artery stenting：JACC state-of-the-art review[J]. J Am Coll Cardiol，2022，80（2）：155-170.
[73] MORESOLI P，HABIB B，REYNIER P，et al. Carotid stenting versus endarterectomy for asymptomatic carotid artery stenosis：a systematic review and meta-analysis[J]. Stroke，2017，48（8）：2150-2157.
[74] YEE E J，WANG S K，TIMSINA L R，et al. Propensity-matched outcomes of transcarotid artery revascularization versus carotid endarterectomy[J/OL]. J Surg Res，2020，252：22-29[2025-02-25]. https://doi.org/10.1016/j.jss.2019.12.003.
[75] KASHYAP V S，KING A H，FOTEH M I，et al. A multi-institutional analysis of transcarotid artery revascularization compared to carotid endarterectomy[J]. J Vasc Surg，2019，70（1）：123-129.
[76] LACKEY A R，ERBEN Y，FRANCO J A D R，et al. Transcarotid artery revascularization results in low rates of periprocedural neurologic events，myocardial infarction，and death[J/OL]. Curr Cardiol Rep，2020，22（1）：3[2025-02-25]. https://doi.org/10.1007/s11886-020-1256-z.
[77] MALAS M B，DAKOUR-ARIDI H，KASHYAP V S，et al. Transcarotid revascularization with dynamic flow reversal versus carotid endarterectomy in the vascular quality initiative surveillance project[J]. Ann Surg，2022，276（2）：398-403.
[78] MALAS M B，DAKOUR-ARIDI H，WANG G J，et al. Transcarotid artery revascularization versus transfemoral carotid artery stenting in the Society for Vascular Surgery Vascular Quality Initiative[J]. J Vasc Surg，2019，69（1）：92-103.
[79] TEXAKALIDIS P，GIANNAKOPOULOS S，KOKKINIDIS D G，et al. Direct transcervical access vs. the transfemoral approach for carotid artery stenting：a systematic review and meta-analysis[J]. J Endovasc Ther，2019，26（2）：219-227.
[80] WU W W，LIANG P，O’DONNELL T F X，et al. Anatomic eligibility for transcarotid artery revascularization and transfemoral carotid artery stenting[J]. J Vasc Surg，2019，69（5）：1452-1460.