What are the criteria for carotid thromboendarterectomy (carotid endarterectomy)?

Criteria for Carotid Endarterectomy (CEA)

Carotid endarterectomy should be performed for patients with symptomatic carotid stenosis of 70-99% within 14 days of symptom onset if the patient is clinically stable, and for selected patients with 50-69% symptomatic stenosis based on patient-specific factors. 1, 2

Symptomatic Carotid Stenosis

Strong Indications (Class I recommendations)

• Severe stenosis (70-99%):

  • Recent TIA or non-disabling stroke within past 6 months
  • Ipsilateral to symptoms
  • Surgery should be performed within 14 days of symptom onset if patient is clinically stable 1, 2
  • Perioperative stroke/death risk must be <6% 1

• Moderate stenosis (50-69%):

  • Recent TIA or non-disabling stroke within past 6 months
  • Ipsilateral to symptoms
  • Consider patient-specific factors (greater benefit in men, patients with recent stroke, and patients with hemispheric symptoms) 1, 3
  • Perioperative stroke/death risk must be <6% 1

• Not indicated for stenosis <50% 1, 2

Asymptomatic Carotid Stenosis

• Severe stenosis (60-99%):

  • May be considered in selected patients 1
  • Patient should have life expectancy >5 years 1
  • Perioperative stroke/death risk must be <3% 1, 4
  • Benefits are smaller compared to symptomatic patients 1

• Not indicated for stenosis <60% 1

Patient Selection Considerations

Favorable Factors

• Male sex (greater benefit shown in trials) 3
• Recent stroke as qualifying event 3
• Hemispheric symptoms (vs. ocular symptoms) 3
• Life expectancy >5 years 1

Contraindications

• Unstable neurological status 2
• Severe disabling stroke (Modified Rankin Scale ≥3) 2
• Chronic total occlusion of the targeted carotid artery 2
• Severe disability that precludes preservation of useful function 2

Surgical Considerations

• CEA should be performed by surgeons/centers with:

  • For symptomatic patients: perioperative stroke/death rate <6% 1
  • For asymptomatic patients: perioperative stroke/death rate <3% 1, 4
  • Regular auditing of performance results 1

• Aspirin (81-325 mg daily) should be administered before CEA and continued indefinitely 2, 5

Carotid Stenting vs. Endarterectomy

• CEA is generally more appropriate than carotid stenting for patients over age 70 1
• Carotid stenting may be considered for patients who are not operative candidates due to:
  • Technical or anatomic reasons 1
  • Medical comorbidities (significant heart/lung disease, age >80 years) 1
  • High carotid bifurcation, carotid re-stenosis 1

Timing of Intervention

• Ideally within the first days following non-disabling stroke or TIA 1
• Within 14 days of ischemic event onset for patients not clinically stable in the first few days 1, 2
• Early intervention provides greater absolute benefit compared to delayed surgery 2

The decision to perform CEA must carefully balance the risks of surgery against the risk of recurrent stroke, with consideration of the patient's specific clinical characteristics, degree of stenosis, and the surgeon's experience and complication rates.