What are the key points to consider for patients undergoing carotid endarterectomy?

From the Guidelines

Patients undergoing carotid endarterectomy (CEA) should be evaluated urgently by an expert team to decide carotid revascularization, and if indicated, CEA should be performed as early as possible, ideally within 14 days after symptoms onset, with a preference for CEA over carotid stenting, unless the patient is not a candidate for CEA due to technical, anatomic, or medical reasons 1.

Key Considerations for Carotid Endarterectomy

• Preoperative management should include antiplatelet therapy, typically aspirin 81-325 mg daily, and statins to reduce perioperative stroke risk and stabilize plaque 1.
• Blood pressure management is critical, aiming for control below 140/90 mmHg preoperatively while avoiding hypotension during the perioperative period.
• Neurological monitoring during surgery is essential, with options including awake surgery under local anesthesia or various monitoring techniques during general anesthesia.

Postoperative Care and Follow-up

• Postoperatively, patients need close monitoring for complications including hyperperfusion syndrome, cranial nerve injuries, wound hematomas, and myocardial infarction.
• Long-term follow-up should include ultrasound surveillance at regular intervals (typically 1 month, 6 months, then annually), continued medical therapy for atherosclerosis, and lifestyle modifications including smoking cessation, diet improvement, and regular exercise 1.
• Diabetes management and cardiac risk assessment are also important considerations, as many CEA patients have concomitant coronary artery disease.

Indications and Timing for CEA

• Patients with an acute ischemic stroke or TIA and ipsilateral internal carotid artery stenosis of 50–99% should be evaluated urgently by an expert team to decide carotid revascularization 1.
• CEA is preferred over carotid stenting for patients over 70 years who are otherwise fit for surgery, as current evidence indicates stenting carries a higher peri-procedural risk of stroke and death in older patients 1.

From the Research

Key Points for Carotid Endarterectomy

• The decision to undergo carotid endarterectomy should be based on individual patient characteristics, including the degree of stenosis, symptoms, and surgical risk 2, 3, 4, 5, 6.
• Carotid endarterectomy is beneficial for patients with symptomatic severe carotid stenosis (70-99% stenosis) with a significant reduction in stroke risk 3, 4, 5.
• For patients with symptomatic moderate stenosis (50-69% stenosis), the benefit of carotid endarterectomy is lower, but may still be justified in selected cases 3, 4, 5.
• Patients with less than 50% stenosis do not benefit from surgery 3, 4, 5, 6.
• Asymptomatic patients with severe stenosis (>70% stenosis) may benefit from carotid endarterectomy, but the benefit is smaller and should be weighed against the risks of surgery 4, 5, 6.

Surgical Considerations

• The surgical technique, including traditional carotid endarterectomy with patching or eversion carotid endarterectomy, may affect outcomes 2.
• The use of cerebral protection, such as continuous electroencephalographic monitoring for selective shunting, may reduce the risk of perioperative stroke 2.
• The experience and skill of the surgeon are critical factors in determining the outcome of carotid endarterectomy 3, 4, 5, 6.

Medical Management

• Best medical management, including lowering blood pressure, treatment with statins, and antiplatelet therapy, is essential for all patients with carotid stenosis 5.
• Medical management alone may be sufficient for patients with less than 50% stenosis or those who are not candidates for surgery 3, 4, 5, 6.