From the Guidelines
Carotid endarterectomy is indicated for patients with significant carotid artery stenosis, particularly those with symptomatic stenosis of 50-99% and asymptomatic stenosis of 60-99%, to reduce stroke risk. The decision to perform carotid endarterectomy should be based on the severity of stenosis, patient-specific factors, and the surgeon's perioperative complication rates.
Indications for Carotid Endarterectomy
- Symptomatic patients with recent (within 6 months) transient ischemic attack or non-disabling stroke and ipsilateral 50-99% carotid stenosis should be considered for carotid endarterectomy, as recommended by the Canadian Stroke Best Practice Recommendations, sixth edition practice guidelines, update 2017 1.
- Asymptomatic patients with 60-99% carotid stenosis may be considered for carotid endarterectomy if they have a life expectancy of more than five years and an acceptable risk of surgical complications, as stated in the same guidelines 1.
Perioperative Management
- Carotid endarterectomy 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 for asymptomatic patients, and less than 6% for symptomatic patients, as recommended by the Canadian Stroke Best Practice Recommendations, sixth edition practice guidelines, update 2017 1 and the 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease 1.
- Perioperative management includes antiplatelet therapy, typically aspirin 81-325 mg daily, continued through the perioperative period, with careful blood pressure control to prevent hyperperfusion syndrome after revascularization.
Timing of Carotid Endarterectomy
- Carotid endarterectomy should be performed within 2 weeks of symptom onset in symptomatic patients when possible, as earlier intervention provides greater benefit, as recommended by the 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease 1 and the Canadian Stroke Best Practice Recommendations, sixth edition practice guidelines, update 2017 1.
Patient-Specific Factors
- Patient-specific factors that influence decision-making include age, sex, comorbidities, and anatomical considerations, as stated in the 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease 1.
- Carotid stenting may be considered in patients with 60-99% carotid stenosis who are not operative candidates for technical, anatomic, or medical reasons, provided there is a less than 3% risk of peri-procedural morbidity and mortality, as recommended by the Canadian Stroke Best Practice Recommendations, sixth edition practice guidelines, update 2017 1.
From the Research
Indications for Carotid Endarterectomy
The indications for carotid endarterectomy (CEA) in patients with carotid artery disease are as follows:
- Symptomatic Carotid Stenosis: CEA is recommended for patients with ≥70-99% symptomatic stenosis 2, 3, 4.
- Asymptomatic Carotid Stenosis: CEA is recommended for patients with ≥60-99% asymptomatic carotid stenosis who are considered to be at increased risk of stroke on best medical treatment (BMT) alone 5, 4.
- Timing of Surgery: CEA should be performed early, ideally within two weeks of the last retinal or cerebral ischemic event in patients with ≥50-99% symptomatic stenosis 6, 4.
- Moderate Stenosis: CEA may be considered for patients with 50-69% symptomatic stenosis 2, 4.
Patient Selection
The decision to perform CEA should take into account the patient's overall health, the presence of comorbidities, and the degree of stenosis. Patients with certain conditions, such as contralateral internal carotid artery occlusion, may benefit from CEA 3.