BACKGROUNDTo estimate revascularization benefit for carotid artery stenosis, with a novel grading system containing symptoms, stenosis, plaque, and collateral compensation (SSPC grading system).METHODSA retrospective multicenter study examined 945 consecutive patients diagnosed with carotid stenosis from January 2013 to December 2017. The cohort was classified into 2 groups: the revascularization group and the best medical therapy (BMT) group. Demographic, clinical, and lesion characteristics of all patients were recorded and 5-year nonprocedural stroke survival was calculated using Kaplan-Meier curve analyses.RESULTSOf the 945 patients, 514 underwent carotid revascularization (483 for carotid endarterectomy and 31 for transfemoral-carotid artery stenting) and 431 patients were treated with BMT. Patients in the revascularization group had a significantly higher proportion of preprocedural stroke/transient ischemic attack (TIA) and grades of stenosis. Of the patients in the revascularization group, 3.1% were classified as SSPC I, 10.3% as SSPC II, 41.4% as SSPC III, and 45.1% as SSPC IV. Meanwhile, 17.9% were classified as SSPC I, 19.7% as SSPC II, 49.2% as class III, and 13.2% had class IV in the BMT group. Procedural stroke developed in 13 patients (2.5%) following revascularization (10 of them were non-disabling). The overall rate of freedom from any nonprocedural stroke was 94.1 ± 1.1% in the revascularization group and 89.5 ± 1.6% in the BMT group (P = 0.01). Subgroup analysis was conducted for asymptomatic carotid stenosis (ACS) and carotid near-occlusion (CNO) patients. Nonsignificance was noted in the rate of freedom from any nonprocedural stroke between revascularization and BMT in both ACS and CNO subgroups (P = 0.09 and 0.12, respectively). Of note, in ACS patients graded as SSPC III, a significant difference in stroke survival was found between the revascularization and BMT group (96.0 ± 2.0% vs. 89.1 ± 2.4%, P = 0.04). Meanwhile, in symptomatic CNO patients, similar results were found regarding SSPC classification (94.8 ± 3.6% vs. 63.8 ± 14.9%, P = 0.01).CONCLUSIONSThe SSPC grading system stratifies the patients with carotid artery stenosis and predicts the long-term benefits of revascularization. Meanwhile, potential revascularization benefits could be better attained via SSPC classes in specific patients with ACS and CNO.