What are the indications for carotid endarterectomy (CEA)?

Indications for Carotid Endarterectomy

Carotid endarterectomy (CEA) is strongly indicated for patients with symptomatic severe (70-99%) carotid stenosis who have experienced a recent TIA or non-disabling stroke within the past 6 months, provided the procedure can be performed with a perioperative complication rate of less than 6%. 1

Symptomatic Carotid Stenosis

Strong Indications (Proven Benefit)

• 70-99% ipsilateral carotid stenosis with:
  • Recent TIA or non-disabling stroke within past 6 months 1
  • Perioperative stroke/death risk <6% 1
  • Ideally performed within 2 weeks of the ischemic event 1

Moderate Indications

• 50-69% ipsilateral carotid stenosis with:
  • Recent TIA or non-disabling stroke 1
  • Patient-specific factors favoring surgery (male sex, recent hemispheric symptoms, irregular/ulcerated plaque) 1, 2
  • Absolute risk reduction of 4.6% at 5 years 3, 4

Not Indicated

• <50% carotid stenosis with TIA or stroke 1
  • Evidence shows no benefit over medical management 2, 4

Asymptomatic Carotid Stenosis

Conditional Indications

• 60-99% carotid stenosis:
  • May be considered in selected patients 1
  • Patient must have life expectancy >5 years 1
  • Perioperative risk must be <3% 1, 5
  • Smaller benefit compared to symptomatic stenosis (reduces stroke risk from ~2% to ~1% per year) 1

Timing of Surgery

• For symptomatic patients:
  • Ideally within first days following non-disabling stroke or TIA 1
  • Within 14 days of ischemic event onset for patients not clinically stable in first few days 1
  • Early intervention (within 2 weeks) rather than delayed surgery is preferred 1

Surgical Considerations

• Procedure should be performed by surgeons/centers with:

  • Regular performance audits 1
  • Perioperative stroke/death rates <6% for symptomatic patients 1
  • Perioperative stroke/death rates <3% for asymptomatic patients 1, 5

• CEA is generally more appropriate than carotid stenting for:

  • Patients >70 years old 1
  • Patients scheduled for revascularization within 1 week of index stroke 1

Carotid Stenting as Alternative

• Carotid stenting may be considered when:
  • Patient is not an operative candidate for technical, anatomic, or medical reasons 1
  • Radiation-induced stenosis or restenosis after CEA is present 1
  • Procedure is performed by interventionist with perioperative stroke/death rates <5% 1

Common Pitfalls and Caveats

• Avoid CEA in patients with <50% stenosis as evidence shows no benefit 1, 4
• Do not delay surgery unnecessarily in symptomatic patients as benefit is greatest when performed early 1
• Ensure accurate measurement of stenosis, ideally by CTA 1
• Remember that benefit of CEA in asymptomatic patients is smaller than in symptomatic patients and requires exceptionally low complication rates 1, 5
• For patients >70 years, CEA is preferred over stenting due to higher periprocedural risk with stenting 1

By following these evidence-based indications, carotid endarterectomy can significantly reduce stroke risk in appropriately selected patients with carotid stenosis.