Revising Carotid Duplex Criteria Helped Identify More Treatable Asymptomatic Stenosis

For clinicians managing atherosclerosis, asymptomatic carotid stenosis remains one of the hardest treatment decisions. When does stroke prevention justify procedural risk in a patient who feels well?

Society for Vascular Surgery guidance supports revascularization in selected asymptomatic patients with more than 70% stenosis and reasonable life expectancy. Yet many high-volume centers, including Cleveland Clinic, have historically used a more conservative 80% threshold.

While this approach may have spared some patients unnecessary procedures, it also raised concern that others with 70%-80% stenosis might remain under surveillance despite potentially benefiting from earlier treatment.

Rethinking the 80% threshold

Findings from the recent CREST-2 trial caused the Vascular Surgery Department at Cleveland Clinic to rethink its criteria, says Cleveland Clinic vascular surgeon Ali Khalifeh, MD.

“Even among patients receiving the best medical therapy for high-grade asymptomatic carotid stenosis, the annual stroke risk was about 1.7%,” he says. “Over five years, that approaches 10%, which is clinically significant.”

As a result, in late 2024, Cleveland Clinic’s vascular surgeons agreed to shift carotid duplex criteria to a 70% threshold, aligning with Intersocietal Accreditation Commission recommendations.

The team anticipated that the revised criteria would identify more asymptomatic patients with severe disease and lead to higher carotid revascularization volume. One year after implementation, procedure volume had increased modestly without a corresponding rise in short-term complications. These findings were presented at the 2026 Vascular Annual Meeting.

Still room for surgeon judgment

“The revised imaging threshold did not automatically trigger intervention,” says Cleveland Clinic vascular surgery resident Nathan Reinert, MD, who presented the findings. “Treatment decisions remained individualized.”

Cleveland Clinic surgeons continue to weigh age, frailty, dialysis dependence, heart failure, pulmonary disease and expected survival before recommending carotid endarterectomy or stenting in patients with stenosis of 70% or more. Revascularization is recommended at 80% stenosis if life expectancy is more than three years.

Structured quality review

In a quality review comparing the year before the transition with the year after it, investigators used Vascular Quality Initiative analytics and internal dashboards to assess procedure volume and in-hospital outcomes.

Key findings included:

• More treatment in the 70%-80% range. Among 25 asymptomatic patients found to have 70%-80% carotid stenosis, all would have remained on medical therapy and surveillance under the prior criteria. After the change, 52% underwent intervention, while 48% continued surveillance. “These results underscore that clinician judgment remains central,” Dr. Khalifeh says. “Our clinicians weighed the risks and benefits, and 48% of the time determined that even though they could choose to operate, it was clinically better to keep watching.”
• Higher procedure volume, driven by endarterectomy. Carotid artery stenting volume was essentially unchanged before and after the transition (72 vs. 70), while carotid endarterectomy volume increased from 225 to 300. Because no hospitals or staff were added during the study period, the increase appears to be attributable to the criteria change rather than program expansion.
• Reassuring imaging performance. Among 113 asymptomatic carotid arteries reviewed after the transition, duplex ultrasound findings agreed with CT angiography in 72% of cases. When duplex ultrasound identified stenosis greater than 70%, CT angiography confirmed severe disease in every case. “That finding suggests the revised criteria were not simply overestimating disease severity,” Dr. Reinert says. “When the new duplex criteria flagged severe stenosis, CT angiography confirmed it.”

Despite higher treatment volume, in-hospital rates of stroke, myocardial infarction, death and return to the operating room remained low after the transition.

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30-day outcomes before and after transition to > 70% revascularization threshold for carotid artery stenosis.

A commitment to vascular quality

“The question for us was whether lowering the threshold from 80% to 70% would put more patients at risk,” Dr. Khalifeh says. “Based on these early results, the answer appears to be no.”

Lowering the duplex threshold to 70% may help identify more patients who could benefit from revascularization without compromising short-term safety, he says.

Cleveland Clinic continues to track vascular surgery outcomes through long-term patient follow-up and participation in the Society for Vascular Surgery’s Vascular Quality Initiative, using those data to drive ongoing quality improvement.

In 2026, Cleveland Clinic became one of a select group of institutions to earn the three-star (highest rated) Commitment to Vascular Quality Improvement Award for eight consecutive years or more.