What are the indications for carotid endarterectomy?

Indications for Carotid Endarterectomy

Carotid endarterectomy should be performed in patients with recent ischemic stroke or TIA who have ipsilateral 70-99% carotid stenosis, ideally within 14 days of symptom onset, provided the surgical team maintains perioperative stroke/death rates below 6%. 1

Symptomatic Carotid Stenosis (Primary Indications)

High-Grade Stenosis (70-99%)

• Patients with nondisabling stroke or TIA within the past 6 months and ipsilateral 70-99% carotid stenosis should undergo carotid endarterectomy urgently 1
• Surgery provides 16% absolute risk reduction at 5 years compared to medical therapy alone 2, 3
• Timing is critical: perform within the first few days if clinically stable, or within 14 days maximum 1
• The surgical team must demonstrate perioperative morbidity/mortality rates <6% 1

Moderate Stenosis (50-69%)

• Carotid endarterectomy may be offered to selected patients with 50-69% symptomatic stenosis, but benefits are substantially lower 1
• Absolute risk reduction is only 4.6% at 5 years 2, 3
• Patient selection is critical based on:
  • Life expectancy >5 years (required to realize benefit) 1
  • Male sex (women with 50-69% stenosis showed no clear benefit in NASCET) 1
  • Age and comorbidities 1
• Higher risk of poor outcomes in first 2 post-procedural years, but significant benefit emerges at 5 years 1
• Surgical team must maintain even lower perioperative rates (<6%) 1

Contraindications for Symptomatic Disease

• Do not perform endarterectomy for <50% symptomatic stenosis 1, 2

Asymptomatic Carotid Stenosis (Selective Indication)

Criteria for Consideration (60-99% stenosis)

• Carotid endarterectomy may be considered for highly selected asymptomatic patients with 60-99% stenosis only if perioperative morbidity/mortality is <3% 1
• Patient must have life expectancy >5 years 1
• The benefit is small: 83 patients must be treated to prevent one stroke in 2 years 4
• Age considerations: benefit diminishes in patients >75 years 3
• Aggressive medical management is mandatory regardless of surgical decision 1

Contraindications for Asymptomatic Disease

• Do not perform endarterectomy for <60% asymptomatic stenosis 1

Critical Surgical Quality Requirements

Mandatory Performance Standards

• Surgery must be performed by surgeons/centers that routinely audit outcomes 1
• Symptomatic patients: perioperative stroke/death rate must be <6% 1
• Asymptomatic patients: perioperative stroke/death rate must be <3% 1
• These thresholds are non-negotiable; benefits disappear if complication rates exceed these levels 2

Carotid Endarterectomy vs. Stenting

When to Choose Endarterectomy

• Carotid endarterectomy is preferred over carotid stenting as the primary intervention 1
• Particularly preferred for patients >70 years, as stenting carries higher perioperative stroke/death risk in older patients 1

When Stenting May Be Considered

• Patients who are not operative candidates due to:
  • Technical reasons (high or low carotid bifurcation) 1
  • Anatomic reasons (carotid re-stenosis) 1
  • Medical comorbidities (significant heart/lung disease, age >80 years) 1
• Stenting should only be performed by experienced interventionalists with audited perioperative stroke/death rates <5% 1

Common Pitfalls and Caveats

Age Considerations

• Age >80 years increases perioperative risk, particularly in symptomatic patients (6.0% stroke/death rate vs 0.9% in asymptomatic octogenarians) 5
• However, age ≥80 alone should not automatically exclude patients if they are otherwise fit 1, 5
• Octogenarians have longer hospital stays (average 3.2 days vs 2.4 days) 5

Medical Complications

• Cardiovascular complications occur in approximately 8% of patients undergoing endarterectomy 6
• Myocardial infarction risk is 1%, with higher risk in patients with history of MI, angina, or hypertension 6
• Most medical complications (69.7%) are short-duration and resolve completely 6

Mandatory Adjunctive Medical Therapy

• All patients must receive intensive medical therapy regardless of whether revascularization is performed 1
• This includes: antiplatelet agents (aspirin 81-325 mg daily preferred over higher doses), lipid-lowering medications, blood pressure management, diabetes control, smoking cessation, diet, and exercise 1, 2