From the Guidelines
Carotid endarterectomy is recommended for patients with recent transient ischemic attack or non-disabling stroke and ipsilateral 50 to 99 percent symptomatic carotid stenosis, and should be performed as soon as possible, ideally within the first days following the event or within 14 days of ischemic event onset. This recommendation is based on the strongest and most recent evidence from the Canadian Stroke Best Practice Recommendations, sixth edition practice guidelines, update 2017 1. The guidelines suggest that patients with 70–99% symptomatic carotid stenosis should undergo carotid endarterectomy on an urgent basis, with a goal of performing the procedure within the first days following the event.
Key considerations for carotid endarterectomy include:
- Symptomatic patients with 50-99% carotid stenosis who have experienced a transient ischemic attack (TIA) or minor stroke within the past 6 months are ideal candidates for the procedure
- Carotid stenosis should be measured by CTA to guide surgical decision-making 1
- The procedure should be performed by a surgeon/center that routinely audits their performance results, especially perioperative stroke and death rates, with a goal of combined perioperative stroke and death rates of 6–7% or less 1
- Carotid endarterectomy is generally more appropriate than carotid stenting for patients over age 70 years who are otherwise fit for surgery, as stenting carries a higher peri-procedural risk of stroke and death in older patients 1
In terms of medical optimization before surgery, patients should be on antiplatelet therapy, such as aspirin 81-325mg daily, and statins are recommended to stabilize plaque. Blood pressure control, with a target of less than 140/90 mmHg, and management of diabetes and other cardiovascular risk factors are also crucial. The procedure removes atherosclerotic plaque from the carotid artery wall, reducing stroke risk by preventing emboli from breaking off and traveling to the brain.
It is worth noting that the evidence from the 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease also supports the use of carotid endarterectomy in symptomatic patients with 50-99% carotid stenosis 1. However, the more recent Canadian Stroke Best Practice Recommendations provide more up-to-date guidance on the optimal timing and patient selection for carotid endarterectomy.
From the Research
Carotid Endarterectomy Recommendations
Carotid endarterectomy is recommended in the following situations:
- For patients with 70 to 99% symptomatic stenosis, as it reduces the stroke risk compared to medical therapy alone 2
- For symptomatic patients with 50 to 69% stenosis, as it has a moderate benefit 2, 3
- For asymptomatic patients with 60 to 99% stenosis, if the perioperative complication rate is low 2
- In the acute phase of crescendo cerebral transient ischemic attacks, as it is safe and effective 4
- For patients with symptomatic low-grade carotid stenosis associated with unstable plaque, as it provides excellent protection against further ischemic events 5
Timing of Carotid Endarterectomy
- Early carotid endarterectomy within 48 hours after transient ischemic attack or stroke in evolution can be performed with an acceptable risk in properly selected symptomatic patients 6
- Delay to surgery after the presenting event should be as short as possible, as benefit from endarterectomy falls rapidly with increasing delay 3
Patient Selection
- Patients with disabling neurologic deficit, cerebral lesions >3 cm in diameter, presence or suspicion of parenchymal hemorrhage, or occlusion of the middle cerebral artery should not undergo carotid endarterectomy 6
- Patients with unstable plaque, as identified by histological examination of carotid plaques, may benefit from carotid endarterectomy 5