What are the indications for carotid endarterectomy (CEA) in women with carotid stenosis?

Carotid Endarterectomy Indications in Women

Women with symptomatic carotid stenosis of 70-99% should undergo carotid endarterectomy, while those with 50-69% stenosis generally do not benefit from the procedure unless they have additional stroke risk factors. 1

Indications Based on Stenosis Severity

Symptomatic Carotid Stenosis

• 70-99% stenosis:

  • Strong indication for CEA in women
  • Similar long-term benefit compared to men (15.1% absolute risk reduction at 5 years) 2
  • Procedure should be performed within 14 days of symptom onset if the patient is clinically stable 1

• 50-69% stenosis:

  • Generally not beneficial for women (unlike men) 1, 2
  • The North American Symptomatic Carotid Endarterectomy Trial (NASCET) showed no clear benefit for women with moderate stenosis 1
  • Consider CEA only for women with high stroke risk profile (see risk stratification below) 2

• <50% stenosis:

  • CEA not indicated (Level A evidence) 3

Asymptomatic Carotid Stenosis

• 60-99% stenosis:
  • Limited evidence of benefit for women
  • No clear evidence that surgery benefits asymptomatic women at 5-year follow-up 4
  • Consider only if perioperative stroke/death rate is <3% 3
  • Benefit/risk ratio is smaller compared to symptomatic patients 3

Risk Stratification for Women with 50-69% Symptomatic Stenosis

CEA may be beneficial for women with 50-69% stenosis who have a high stroke risk profile using the Stroke Prognosis Instrument (SPI-II) 2:

Points assigned for risk factors:

• 3 points each: Hemispheric (not retinal) event, history of diabetes, previous stroke
• 2 points each: Age >70 years, stroke (not TIA)
• 1 point each: Severe hypertension, history of myocardial infarction

Decision algorithm:

• Total score 8-15: Consider CEA (8.9% absolute risk reduction) 2
• Total score <8: Medical therapy preferred (no significant benefit from CEA) 2

Perioperative Considerations for Women

• Women have higher perioperative mortality compared to men (2.3% vs 0.8%) 2
• Higher perioperative risk of stroke and death is observed in women (7.6% vs 5.9%) 2
• CEA should only be performed if the surgical team's morbidity/mortality risk is <6% 1
• Aspirin 81-325 mg daily is preferred before and after CEA 3

Timing of Intervention

• For symptomatic patients, CEA should be performed as early as possible if clinically stable, ideally within 14 days after symptom onset 1
• The benefit of early intervention must be balanced against the potentially higher perioperative risk in women

Alternative Approaches

• Carotid endarterectomy is preferred over carotid stenting 1
• Carotid stenting may be considered only for patients who are not candidates for CEA due to technical, anatomic, or medical reasons 1
• Intensive medical therapy (antiplatelet agents, lipid-lowering medications, blood pressure management, diabetes control) is recommended for all patients regardless of whether revascularization is performed 1

Important Caveats

• The benefit of CEA in women with 50-69% stenosis is substantially lower than in men (10.0% absolute risk reduction for men vs. 3.0% for women) 2
• Medically treated women generally have lower stroke risk than men, which reduces the potential benefit of surgical intervention 2
• Life expectancy should be considered, as benefits for moderate stenosis may only become apparent after 5 years 1
• The surgical team's experience and complication rates are critical factors in determining whether CEA should be offered 1, 5