What is the recommended treatment for significant carotid artery stenosis, particularly for patients with symptoms, and when is endarterectomy (carotid endarterectomy) indicated?

Carotid Endarterectomy for Carotid Artery Stenosis

Carotid endarterectomy (CEA) should be performed urgently for patients with recent TIA or non-disabling stroke who have 70-99% ipsilateral symptomatic carotid stenosis, ideally within the first few days after neurological stabilization and no later than 14 days from symptom onset. 1

Symptomatic Carotid Stenosis (Recent TIA or Stroke)

70-99% Stenosis (Excluding Near-Occlusion)

• CEA is highly beneficial and strongly recommended for this degree of stenosis, reducing 5-year ipsilateral stroke risk from 26% with medical therapy alone to 9% with surgery (16% absolute risk reduction). 2, 3, 4
• Surgery must be performed within 14 days of the ischemic event, with greatest benefit achieved when performed within the first few days after the patient becomes neurologically stable. 1, 5
• The perioperative stroke/death rate must be documented at <6% by the surgical team/center through routine auditing. 1, 5, 6
• Approximately 90% of contemporary guidelines endorse CEA as routine treatment for this degree of stenosis. 5

50-69% Stenosis

• CEA provides moderate benefit for selected patients, with a smaller absolute risk reduction of 4.6% at 5 years. 2, 3, 4
• Surgery may be offered to patients in this range, but the benefit is substantially lower than for severe stenosis. 1, 6
• Benefit is greatest among men, patients with recent stroke (rather than TIA) as the qualifying event, and those with hemispheric symptoms. 3

<50% Stenosis

• CEA is not indicated as patients do not benefit from surgery. 2, 3

Near-Occlusion

• CEA provides minimal to no benefit for near-occlusions despite high-grade stenosis measurement. 4

Asymptomatic Carotid Stenosis

60-99% Stenosis

• CEA may be considered only in highly selected patients with life expectancy >5 years and when the surgical team demonstrates perioperative stroke/death rates <3%. 1, 5, 6, 2
• The benefit/risk ratio is substantially smaller compared to symptomatic patients, with only modest stroke risk reduction. 1, 2
• Approximately 86% of guidelines endorse CEA for asymptomatic stenosis, though most specify it "may be provided" rather than "should be provided." 5

CEA versus Carotid Artery Stenting (CAS)

Age-Based Recommendations

• CEA is generally preferred over CAS for patients >70 years of age who are otherwise fit for surgery, as stenting carries higher perioperative stroke and death risk in older patients. 1, 5, 6

When to Consider CAS

• CAS may be considered for patients who are not operative candidates due to technical, anatomic, or medical reasons (e.g., contralateral carotid occlusion, severe coronary artery disease, previous radical neck surgery or radiation, recurrent stenosis after prior CEA). 1, 5
• CAS should only be performed by interventionalists/centers with documented perioperative stroke/death rates <5% through routine auditing. 1, 6

Critical Quality Metrics (Non-Negotiable)

Symptomatic Patients

• Perioperative stroke/death rate must be <6%. 1, 5, 6, 2

Asymptomatic Patients

• Perioperative stroke/death rate must be <3%. 1, 5, 6, 2

Surgical Team Requirements

• The surgeon/center must routinely audit performance results and demonstrate compliance with these thresholds. 1, 5, 6

Mandatory Adjunctive Medical Therapy

All patients with carotid stenosis must receive intensive medical management regardless of whether revascularization is performed:

• Antiplatelet therapy: Low-dose aspirin (81-325 mg daily) is preferred over higher doses (650-1,300 mg daily) to reduce stroke, MI, and death. 2
• Statin therapy for aggressive lipid management. 1, 5, 6
• Antihypertensive agents with careful blood pressure control (elevated diastolic blood pressure is an independent risk factor for perioperative complications). 1, 7
• Diabetes management if applicable. 5, 6
• Smoking cessation. 5, 6

Timing Considerations

Symptomatic Patients

• Ideally perform CEA within the first few days following non-disabling stroke or TIA once the patient is neurologically stable. 1, 5
• Maximum window is 14 days from ischemic event onset for patients who are not clinically stable in the first few days. 1, 5
• The benefit of surgery diminishes significantly beyond this timeframe, though trials showed benefit up to 6 months. 1, 2

Common Pitfalls to Avoid

• Do not perform CEA for symptomatic stenosis <50% as there is no benefit. 2, 3
• Do not proceed with CEA if the surgical team cannot demonstrate perioperative complication rates below the specified thresholds (<6% for symptomatic, <3% for asymptomatic). 1, 5, 6
• Do not use CAS routinely in patients >70 years when they are otherwise fit for CEA. 1, 5
• Do not delay surgery beyond 14 days in symptomatic patients, as benefit decreases substantially. 1, 5
• Do not forget mandatory medical therapy even when performing revascularization, as optimal medical management is essential for long-term outcomes. 1, 5, 6
• Monitor blood pressure carefully perioperatively, as elevated diastolic blood pressure is an independent risk factor for complications. 7

Measurement of Stenosis

• CTA is the preferred imaging modality to guide surgical decision-making. 1
• Ensure consistent methodology for measuring stenosis, as trials used different methods (NASCET vs. ECST criteria). 1, 3

Postoperative Considerations

• 21.2% of perioperative events occur on or after the day of discharge, requiring vigilant outpatient monitoring. 7
• Median hospital stay is 4 days following CEA. 7
• Annual follow-up is recommended to assess neurological symptoms, cardiovascular risk factors, medication adherence, and surveillance for restenosis. 8, 5