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 the first days following a nondisabling stroke or transient ischemic attack, as supported by the highest quality evidence [@\1@]. The indications and guidelines for CEA in patients with carotid stenosis are based on the severity of stenosis and symptom status.
Key Indications for CEA
- Symptomatic patients with 70-99% carotid stenosis should undergo CEA as soon as possible [@\1@].
- For symptomatic patients with 50-69% carotid stenosis, CEA may be considered, but the decision should be individualized based on patient factors and surgical risk [@\1@].
- Asymptomatic patients with 60-99% carotid stenosis may be considered for CEA if they have a life expectancy of more than five years and an acceptable risk of surgical complications [@\3@].
Important Considerations
- CEA should be performed by a surgeon or center that routinely audits their performance results, with a perioperative stroke and death rate of less than 3% [@\1@, @\3@].
- Carotid stenting may be considered for patients who are not operative candidates for technical, anatomic, or medical reasons, but the peri-procedural risk of stroke and death should be less than 3% [@\1@, @\3@].
- The choice between CEA and carotid stenting should be based on individual patient factors, including age, comorbidities, and surgical risk, with CEA generally preferred for patients over 70 years old who are fit for surgery [@\1@].
Timing of CEA
- For symptomatic patients, CEA should be performed within 14 days of the ischemic event onset, with ideally within the first days following a nondisabling stroke or transient ischemic attack [@\1@].
- The timing of CEA for asymptomatic patients is not as urgent, but the procedure should still be performed in a timely manner to reduce the risk of stroke [@\3@].
From the Research
Indications for Carotid Endarterectomy
- Carotid endarterectomy (CEA) is indicated for patients with symptomatic severe carotid stenosis (70-99%) 1, 2, 3, 4
- CEA is moderately useful for patients with 50-69% symptomatic stenosis 1, 3, 4
- CEA is not indicated for patients with symptomatic stenosis of less than 50% 1, 2, 3, 4
- 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 2, 4
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 2
- 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 2
- Acceptable but not proven indications for CEA include symptomatic patients with moderate stenosis (50-69%) and asymptomatic patients with moderate stenosis (50-69%) 2
Benefits and Risks of Carotid Endarterectomy
- CEA reduces the stroke risk compared to medical therapy alone for patients with 70-99% symptomatic stenosis 1
- CEA has a smaller benefit for patients with 50-69% symptomatic stenosis 1, 3
- The benefit of CEA is durable for up to 8 years in patients with severe stenosis 3
- The risk of CEA includes perioperative stroke and death, which should be kept below 3% for asymptomatic patients and 6% for symptomatic patients 2, 4