What is the optimal timing for performing a carotid endarterectomy?

From the Guidelines

For symptomatic patients with transient ischemic attack (TIA) or non-disabling stroke, carotid endarterectomy (CEA) should ideally be performed within 14 days of symptom onset, with greatest benefit when done within 48-72 hours, as recommended by the 2024 ESC guidelines 1.

Key Considerations

• The timing of CEA depends on the patient's clinical presentation and the degree of carotid stenosis.
• For symptomatic patients with 70%–99% internal carotid artery (ICA) stenosis, CEA is recommended if the perioperative morbidity and mortality risk is estimated to be <6% 1.
• The procedure should be performed by a surgeon or center with a documented low risk of perioperative complications, and the patient should be medically optimized before surgery.

Benefits and Risks

• Early intervention with CEA significantly reduces the risk of recurrent stroke, as the highest risk period for recurrence is within the first few days to weeks after the initial event 1.
• The decision for CEA timing must balance the risk of perioperative complications against the benefit of stroke prevention, considering the patient's comorbidities and the surgeon's experience.

Preoperative Evaluation

• Preoperative imaging with carotid duplex ultrasound, CTA, or MRA should confirm the degree of stenosis.
• Patients should be medically optimized with antiplatelet therapy, statins, blood pressure control, and diabetes management if applicable, before undergoing CEA.

Asymptomatic Patients

• For asymptomatic patients with significant carotid stenosis (typically >70%), the timing of CEA is less urgent and should be based on individual risk assessment, considering factors such as stenosis progression, plaque characteristics, and the patient's overall surgical risk and life expectancy 1.

From the Research

Optimal Timing for Carotid Endarterectomy

The optimal timing for performing a carotid endarterectomy (CEA) is a topic of ongoing debate. Several studies have investigated the ideal time frame for CEA in patients with symptomatic carotid stenosis.

• A systematic review of literature on the timing of CEA for symptomatic carotid stenosis found that patients who undergo urgent CEA (within 48 hours) after a transient ischemic attack (TIA) have a lower periprocedural risk compared to those who had a stroke as the index event 2.
• Another study suggested that CEA can be performed earlier than 6 weeks after an acute stroke in select patient populations, such as those with complete or near resolution of symptoms, small infarcts on imaging, and ipsilateral carotid stenosis 3.
• A comprehensive review of the literature on the timing of CEA found that urgent CEA (within 24 to 72 hours) can be safe and effective in patients presenting with repetitive transient ischemic attacks or progressing stroke 4.
• A study on the outcomes of CEA in patients with severe internal carotid artery stenosis who underwent surgery in the acute phase of crescendo cerebral transient ischemic attacks found that CEA can be performed safely and effectively within 2 weeks of the first-ever TIA 5.
• A systematic review and meta-analysis of the timing of carotid intervention in symptomatic carotid artery stenosis found that expedited CEA (within 2 days of symptom onset) is safer than transfemoral carotid artery stenting (CAS) and complies with accepted thresholds in international guidelines 6.

Key Considerations

When determining the optimal timing for CEA, several factors should be considered, including:

• The type of index event (TIA or stroke)
• The severity of carotid stenosis
• The presence of neurologic instability
• The size of the infarct on imaging
• The patient's overall medical condition
• The availability of surgical expertise and resources

Timing Recommendations

Based on the available evidence, the following timing recommendations can be made:

• For patients with TIA as the index event, CEA can be performed urgently (within 48 hours) 2, 6.
• For patients with stroke as the index event, CEA can be performed within 7 days 2 or 2 weeks 4 of symptom onset.
• For patients with neurologic instability, such as those with repetitive transient ischemic attacks or progressing stroke, urgent CEA (within 24 to 72 hours) can be safe and effective 4.