What is the difference between carotid endarterectomy and carotid artery revascularization (including stenting) for treating carotid stenosis?

Difference Between Carotid Endarterectomy and Carotid Artery Revascularization

Carotid endarterectomy (CEA) is the preferred surgical procedure over carotid artery stenting (CAS) for most patients with symptomatic carotid stenosis due to lower periprocedural stroke risk, particularly in patients over 70 years of age. 1

Key Differences Between Procedures

Carotid Endarterectomy (CEA)

• Procedure technique: Open surgical procedure involving a neck incision to directly remove atherosclerotic plaque from the carotid artery
• Anesthesia: Typically performed under general anesthesia
• Complications: Higher risk of:
  • Myocardial infarction (1.1% vs 2.3% with CAS) 2
  • Cranial nerve injury
  • Neck hematoma
  • Wound infection
  • Cervical strain

Carotid Artery Stenting (CAS)

• Procedure technique: Minimally invasive percutaneous approach using a catheter to deploy a stent
• Anesthesia: Usually performed under local anesthesia
• Complications: Higher risk of:
  • Periprocedural stroke (4.1% vs 2.3% with CEA) 2
  • Hypotension/bradycardia
  • Requires shorter recovery period

Indications and Efficacy

For Symptomatic Carotid Stenosis

• CEA is strongly recommended for patients with recent TIA or non-disabling stroke and 70-99% ipsilateral carotid stenosis 1
• CEA should be performed within the first days following non-disabling stroke or TIA, or within 14 days of ischemic event onset 1
• For 50-69% stenosis, CEA may be considered depending on individual characteristics, with less benefit than for ≥70% stenosis 1

For Asymptomatic Carotid Stenosis

• The benefit of intervention is less clear compared to optimal medical therapy
• The absolute risk reduction for stroke with CEA vs. medical therapy is only 4.6% at 10 years 1
• High-risk features that may warrant intervention include:
  • Contralateral TIA/stroke
  • Ipsilateral silent infarction
  • Stenosis progression (>20%)
  • Large or echolucent plaques 1

Comparative Outcomes

Periprocedural Period (30 days)

• Stroke risk: Higher with CAS (4.1% vs 2.3% with CEA) 2
• Myocardial infarction risk: Higher with CEA (2.3% vs 1.1% with CAS) 2
• Death risk: Slightly higher with CAS (0.7% vs 0.3% with CEA) 2
• Age effect: For patients ≥70 years, CEA has significantly better outcomes (OR for periprocedural death/stroke with CAS vs CEA: 2.23) 3

Long-term Outcomes

• After the periprocedural period, both procedures have similar efficacy in preventing ipsilateral stroke 2, 3
• Restenosis rates are higher after CAS than CEA 3

Patient Selection Considerations

CAS May Be Preferred For:

• Patients with high surgical risk for CEA 1, 4
• Post-radiation or post-surgical stenosis
• Hostile neck anatomy or tracheostomy
• Contralateral laryngeal nerve palsy
• Severe comorbidities contraindicating CEA 4

CEA Is Preferred For:

• Most symptomatic patients, especially those ≥70 years old 3
• Patients with difficult vascular access for CAS
• Patients with heavy calcification or tortuous vessels

Operator Experience and Volume

Both procedures should only be performed by experienced teams with demonstrated low complication rates:

• <3% combined death/stroke rate for asymptomatic patients
• <6% combined death/stroke rate for symptomatic patients 4

Medical Therapy

Regardless of revascularization method, all patients should receive:

• Antiplatelet therapy
• Lipid-lowering medications
• Blood pressure management
• Diabetes control if applicable
• Lifestyle modifications (diet, exercise, smoking cessation) 1

For CAS specifically, dual antiplatelet therapy with aspirin and clopidogrel is recommended for at least 1 month 4

Common Pitfalls

1. Delaying treatment: For symptomatic patients, CEA should ideally be performed within days of the event, as benefit decreases with time
2. Inappropriate patient selection: Not all asymptomatic patients benefit from intervention
3. Ignoring operator experience: Outcomes are highly dependent on operator/center volume and experience
4. Neglecting medical therapy: Optimal medical management remains essential regardless of revascularization

In conclusion, while both CEA and CAS are effective for stroke prevention in appropriately selected patients with carotid stenosis, CEA generally shows better periprocedural safety outcomes, particularly in older patients. The choice between procedures should consider patient age, comorbidities, anatomy, and operator experience.