From the Guidelines
Carotid endarterectomy (CEA) is strongly recommended for patients with symptomatic carotid stenosis of 70-99% and should be performed urgently, ideally within 14 days of ischemic event onset, to reduce stroke risk and improve outcomes. The indications and guidelines for CEA are based on the severity of carotid stenosis and symptom status. For symptomatic patients, CEA is indicated for stenosis of 50-99%, with a strong recommendation for 70-99% stenosis 1. The procedure should be performed by experienced surgeons in centers with low complication rates, with a perioperative stroke and death rate of less than 6-7% 1.
Key Considerations
- CEA is generally more appropriate than carotid stenting for patients over 70 years who are otherwise fit for surgery, as stenting carries a higher peri-procedural risk of stroke and death in older patients 1.
- Carotid stenting may be considered for patients who are not operative candidates for technical, anatomic, or medical reasons, with a peri-procedural stroke and death rate of less than 5% 1.
- Medical optimization should accompany surgical planning, including antiplatelet therapy, statin therapy, blood pressure control, smoking cessation, and diabetes management.
- The timing of surgery is crucial, with CEA ideally performed within 2 weeks of symptom onset to maximize stroke prevention benefits 1.
Asymptomatic Carotid Stenosis
- CEA may be considered for selected patients with 60-99% carotid stenosis who are asymptomatic or were remotely symptomatic, with a life expectancy of more than 5 years and an acceptable risk of surgical complications 1.
- Patients should be evaluated to determine eligibility for CEA, with a focus on aggressive medical management of risk factors, including blood pressure, cholesterol, antiplatelet therapy, and lifestyle changes 1.
Surgical Performance
- CEA should be performed by a surgeon who routinely audits their performance results and demonstrates a less than 3% risk of peri-operative morbidity and mortality 1.
- Carotid stenting may be considered in patients with 60-99% carotid stenosis who are not operative candidates, provided there is a less than 3% risk of peri-procedural morbidity and mortality 1.
From the Research
Indications for Carotid Endarterectomy
- Carotid endarterectomy (CEA) is indicated for patients with symptomatic severe carotid stenosis (70-99%) 2, 3, 4, 5
- CEA is moderately useful for patients with 50-69% symptomatic stenosis 2, 4, 5
- CEA is not indicated for patients with symptomatic stenosis of less than 50% 2, 3, 4, 5
- For asymptomatic patients, CEA may be useful for select patients with severe asymptomatic stenosis (80-99%) but only if the surgical complication is kept below the 3% level 3, 5
Guidelines for Carotid Endarterectomy
- The American Heart Association has developed guidelines for CEA, which include proven, acceptable but not proven, uncertain, and proven inappropriate indications 3
- Proven indications for CEA include symptomatic patients with severe stenosis (70-99%) and asymptomatic patients with severe stenosis (80-99%) if the surgical complication rate is low 3
- Acceptable but not proven indications for CEA include symptomatic patients with moderate stenosis (50-69%) and asymptomatic patients with moderate stenosis (50-69%) 3
Benefits and Risks of Carotid Endarterectomy
- CEA reduces the stroke risk compared to medical therapy alone for patients with 70-99% symptomatic stenosis 2
- CEA has a smaller benefit for patients with 50-69% symptomatic stenosis 2, 4
- The benefit of CEA is durable for up to 8 years in patients with severe stenosis 4
- The risk of CEA includes perioperative stroke and death, which should be kept below 3% for asymptomatic patients and 6% for symptomatic patients 3, 5